THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOCIETY
 
 Peroral Lndoscopy and 
 Laryngeal Surgery 
 
 BY 
 
 CHLVALILR JACKSON, M. D. 
 
 'rofessor of l.aryiigology, University of I'ittsbiirgli ; Consulting l.aryngologisl 
 Bronchoscopist, Esophagoscopist, and Gastroscopist, Western Pennsylvania 
 Hospital ; Laryngologist, Presbyterian Hospital ; Laryngologist, Eye and Ear 
 Hospital ; Consulting Laryngologist, Western Pennsylvania Hospital for the 
 Insane; Consulting Laryngologist, Bronchoscopist, Esophagoscopist and 
 Gastroscopist, Montetiore Hospital; Consulting Laryngologist, Bron- 
 choscopist, Esophagoscopist and Gastroscopist, St. Francis Hospital ; 
 Consulting Laryngologist, Bronchoscopist, Esophagoscopist and 
 Gastroscopist, Passavnnt Hospital : Bronchoscopist and 
 Esophagoscopist, Allegheny General Hospital; Bronchoscopist 
 and I'.sophagoscopist, Pittslwrgh Hospital for Cliililrcn. 
 
 WITH SIX COLOKKD PLATES AND 
 490 ILIA S'l'KATIONS. 
 
 SAINT LOUIS. MO.. U. 5. A. 
 
 THE. LARYNGOSCOPE COMPANY, PUBLISHERS. 
 
 1915
 
 Copyright, ]!tM 
 By Chkvai.ikr Jackson. 
 All Rights Reservkd.
 
 
 
 Unrr 
 
 HIS" 
 
 To 
 
 Mv MoTHliR 
 
 T(i W'liosK IxTi':Ri;s'r in Mkdical Scienck 
 Till'; AuTHciR (JwEs His Incicmui':, 
 
 And to 
 
 Mv Fatiikk 
 
 WiiosK Constant Advici: to 
 
 ■'Edl'cati-: Till-; Evic and tiu-; Fingi;ks" 
 
 Si-i'RRKD Tin; Altiior to Continual Ei'i-ort, 
 
 Tins Book is Atfectionatkly Dkdicaticd. 
 
 ^^4i^86
 
 Preface. 
 
 A number of repetitions of fundamental facts have been necessary 
 in order to facilitate ready reference in the limited time available for 
 the busy surgeon without perusing the entire book. But, as full repeti- 
 tir)ns were ini]>ossible. it is hojied IJiat. for full coniprehcnsidn, the en- 
 tire book shall have been previously read. Symi)toms are referred to 
 only in so far as they concern indications or contraindications for endo- 
 scopy. Diagnosis is referred to only in so far as it is to be made endo- 
 scoi)ically. .\n earnest effort has been made to give due credit to every- 
 one so far as possible within the limits of a practical manual. This effort 
 resulted in such an enormous niunber of references that, to sa\e repeti- 
 tion, the references are all compressed into a numerical "liibliography ' 
 at the end of the hook, referred to in the text as "Uib." followed liy the 
 number. The author cites his personal experiences for what tlie\- may 
 be worth ; and he apologizes for the frequency of these citations, which 
 is necessitated by the newness of the field, and the nature of the book. 
 The French saying: "Neither never nor always" is particularly appli- 
 cable to surgery. The author has tried to make the use of these words 
 as rare as ))ossible because "circumstances alter cases," and great injus- 
 tice might follow dogmatic assertions. For literary shortcomings, the 
 author asks indulgence because, even if he were more capable, literary 
 work, as with all clinicians, is done under stress of limited time and op- 
 portunity L'niess otherwise credited, the illustrations are jihotograiihic 
 reproductions of drawings and jjaintings by the author who solely is 
 responsible for illustrative errors and shortcomings. 
 
 Thanks are due. first of all, to the great master, I'rof. Killian. for 
 kindlv consiijcration .-uid for doing me the honor of writing the Chapter 
 on Sus])ension Laryngoscopy. I'dr the translation of that Cluijiter the 
 author is indebted lo Dr. j. .\. llageman. and for editing the translation, 
 as well as for valualile advise and assistance, to Dr. M. .\. (loldstein. 
 I"r)r aid in the literar\' work the ;u)tlu)r acknowledges his great obligations 
 to Miss Josephine W. W bile. Thanks are due to Miss liabette Kahn 
 for tlie careful |)re]iar;ition of the very comjilete index, h'or the accuracy 
 of case records and for assistance in all phases of the work, clinical
 
 and literary, thanks are due to that able endoscopist. Dr. Ellen J. Patterson. 
 The author wishes here to express his appreciation of tiie part taken 
 liy the following associates with whom he has for years worked shoidder 
 to shoulder and without whose aid whatever measures of success that 
 may have been attained would have been impossible : 
 
 Drs. Patterson. P.oyce. Price, Clark. McCready, Lichtenfels, McKee, 
 Fisher, Sim][)son. l^'pham, Spiro; Mrs. P.raddow ; Misses Ketcham. Saun- 
 ders. Eissler, Bear, Dice, Talbot, Lewellyn, Symes and Piird. 
 
 T-ast, and not the least important, the author's thanks are due to 
 the profession, general and special, at home and abroad, for the clinical 
 material and the hearty support which have rendered this book possible. 
 Especial assurances of appreciation are due the staflfs of various hospitals 
 with which the author was not connected, for their broadmindedness in 
 sanctioning the author's aid in the relief of ward sufferers. 
 
 Chevalier Jackson. 
 
 l^ittsbnrgh, Pa., July, l'.il4.
 
 Contents. 
 
 Chapter I. Instnimciits. 
 
 Chai)tcr II. .\natoni\-. 
 
 Chapter III. Preparation of the Patient f(^r Peroral Eiuioscopy. 
 
 Chapter 1\'. Anesthesia for Peroral Endo-eopy. 
 
 Chapter \'. I'.ronclioscopie Uxygen Insufflation. 
 
 Chapter \I. I'o^iition of the Patient for Peroral Endoscopy. 
 
 Chapter \ 11. Direct Laryngoscopy. 
 
 Chapter \'III. Suspension Laryngoscopy. 
 
 Chapter IX. Introduction of the Bronchoscope. 
 
 Chapter -\. Introduction of the Esophagoscope. 
 
 Chapter XL Ac(|uiring Skill. 
 
 Chai)ter .XIl. I'oreign llodies in the Air and I'ood Passages. 
 
 Chapter XI II. Eoreign I'.odies in the Larynx and Tracheobron- 
 
 chial Tree. 
 
 Chapter Xl\ . Remu\al of l'"oreign IJodics from the Larynx. 
 
 Cha])ter W. .Mechanical Problems of P.ronchoscopic Foreign 
 
 P>ody Extraction. 
 
 Chapter X\'l. I'oreign P.odies in the P.ronchi for Prolonged 
 
 Periods. 
 
 Chajiter X\ 11. L'nsuccessful Cases of llronchoscojiy for Foreign 
 
 I'.odies. 
 
 Chapter X\'11I. I'oreign liodies in the Eso]>hagus. 
 
 Chapter XIX. I'.sophagoscopy for l"oreign I'.odies.
 
 Chapter 
 
 XX 
 
 Cliai'tLT 
 
 XXI 
 
 Cliaiiter 
 
 XXII 
 
 Cliaiiter 
 
 xxm 
 
 Chapter 
 
 XXI\' 
 
 Chapter 
 
 XXV 
 
 Chapter 
 
 XX\1 
 
 i>:stri'mi-:nts. 
 
 Plenroscopy. 
 
 XXI. Ilhistrative Cases of Endoscopy for Foreign RocHes 
 in the Air and Food Passages. 
 
 Benign Growths in the Larynx. 
 
 Benign Growths IVimary in the Tracheobronchial 
 Tree. 
 
 Benign Xeoplasms of tlie Esophagus. 
 
 Endoscopy in Mahgnant Disease of the Larynx. 
 
 Bronchoscopy in .Malignant Growths of the 
 Trachea. 
 
 Chapter XX\'II. Malignant Disease of the Esophagus. 
 
 Chapter XX\"I1I. I^irect Lar}'ngosco])y in Diseases of the Larvnx. 
 
 Chapter XXIX. Bronchoscopy in Diseases of the Trachea and 
 Bronchi. 
 
 Chajiter XXX. Diseases of the Esophagus. 
 
 Chapter XXXI. Diseases of the Esophagus (Continued). 
 
 Chapter XXXII. Diseases of the Esophagus ( Continued ). 
 
 Chapter XXXIll. Di.'ieases of the Esophagus ( Continued ). 
 
 Chapter XXXIN'. Diseases of the Esophagus ( Continued 1. 
 
 Chapter XX X\'. Gastroscopy. 
 
 Chapter XXX\'I. External Lar}ngeal Surgery. 
 
 Chapter XXXVII. Tracheotomy. 
 
 Chapter XXXVIII. Chronic Stenosis of the Larynx and Trachea. 
 
 Chapter XXXIX. Intubational Dilatation of Chronic Laryngeal 
 Stenoses. 
 
 Laryngostomy. 
 
 Decannulation .\fter Cure of Chronic Laryngeal 
 Stenosis. 
 
 Malignant Disease of the Larynx. 
 
 ?\lalignant Disease of the Larynx (Continued). 
 
 Technic of Thyrotomy for Malignant Disease of 
 the Larj'nx. 
 
 Technic of Larvngectomv. 
 
 Chapter 
 
 XL, 
 
 Chapter 
 
 XLI, 
 
 Chajiter 
 
 XLII 
 
 Chapter 
 
 XLllI 
 
 Chapter 
 
 XLIV 
 
 Chai>tcr 
 
 XL\' 
 
 Chapter 
 
 XL\"I
 
 Part I.
 
 CHAPTER I. 
 
 Instruments. 
 
 Since the author's earlier work was ])iiblished a large number 
 of new instruments and modilications of old forms have been devised. 
 Each of them is probably useful to others besides the originators; but 
 it is clear that there will never be a universal instrument. Each endo- 
 scopist will work successfully with those instruments to which he is 
 accustomed. ]'>y this it is not meant that a wise selection is of no im- 
 portance: quite tlie contrary. In general surgery, if knives are sliarp, 
 instrumental e(|uipment is of minor importance. In endoscopy, however, 
 the instrumenlarium is an absolutely fundamental element for success. 
 It is no wonder that some of the laryngologists who have taken up endos- 
 copy have been discouraged, when one looks at the miserably inefticient. 
 clumsy instruments with which their first attemi)ts were made. I n- 
 fortunately there are many bad mechanics in the world, an<l surgeons 
 who have originated excellent, practical ideas are chagrined to find that 
 failures due to faulty workmanship are blamed, not on the incompetent 
 mechanic who made the jiarticular instrument that failed, but upon the 
 originator who is getting excellent results from a well-made inslrument 
 of correct model. All long instruments, such as forceps, canuulae. 
 stylets, probes, siionge holders, and tiie like, should be of spring tem- 
 pered steel or spring brass in order n(jt to get bent, as a bent instrument 
 is much more dit'licuit to manage accurately. ( )n the other hand the 
 temper of steel nuist not be so hard as to risk bieaking, which might 
 be a disaster. There is a "ha])py medium" in the temper of steel that 
 a reliable workman can be depended upon to produce, that will bend 
 slightly to extreme pressure without breaking. 
 
 Tubes and illuminating/ dcz-iccs. The personal equation enters so 
 largely into the choice of instruments that the author urges the reader 
 to get for selection differently illuminated instruments and try them on 
 the dog. using first the largest tubes ;md then tiie smallest, keeping in
 
 13 
 
 INSTRUMENTS. 
 
 mind that it is in the use of small tubes that the greatest difficulties 
 lie; and unfortunately, most of the cases encountered are in children 
 where small tubes are obligatory. All forms of illumination have been 
 greatly improved by the development of the tungsten lamp. Quite a 
 number of new forms of illumination and new tubes have been devised, 
 and they practically all have done good service in the hands of skillful 
 men. In the statistics which the author gathered, there is practically 
 no difference either in the mortality or the percentage of successful re- 
 movals of foreign bodies between the different kinds of tubes and illum- 
 
 W' .^[.\-i.\-r-i-\-i 1 h I I i 1 ^ 1 1 I I i"i I I I P°i 
 
 Fig. I. Ingals' bronchoscope and open laryngeal speculum. 
 
 ination. Far more depended on the individual skill of the operator. Doubt- 
 less, the best instrument for each operator is the one with which he has 
 practiced most. 
 
 Killian still uses the Kirstein headlamp except for demonstration 
 purposes. The lamp is very much improved in construction and has 
 enormously greater illuminating power. 
 
 Guisez has abandoned his triple endoscopic headlamp, and now uses 
 the Claar reflector (Fig. ii). 
 
 The lirimings sliding tubes described in the appendix of the earlier 
 book have been much improved and are extensively used. ( Figs. 2. 3. 
 and 4.)
 
 INSTRUMKNTS. 
 
 i; 
 
 D. R. Patterson has modified the JJrunings tubes b}' placinji; the 
 beak on the inner tube and the cylindrical end on the outer tube, always 
 introducing the instrument with the distal end of the inner tube ex- 
 tended beyond the distal end of the outer tube. 
 
 Excellent work is being done in Chiari's clinic and elsewhere with 
 Kahler's bronchoscopes and esophagoscopes. They are double tubes, one 
 sliding within the other like the ISninings instruments, but the illum- 
 inating mechanism is different. (Fig. 8.) 
 
 Schoonmaker has devised an excellent sliding double-tube broncho- 
 scope. 
 
 Figs. 2 and 3. Brunings' two illuminating handles for laryngoscopes, bron- 
 choscopes, and esophagoscopes. 
 
 Ingals uses an improved form of his original distally illuminated 
 bronchoscope (Fig. J), with which he has done some remarkablv suc- 
 cessful work. 
 
 .Mosher uses esojiiiagoscopes of very large transverse diameter with 
 distal illumination. (Fig. .5.) 
 
 ICfi'orts to j)roducc jointed and angular esophagoscopes and gastro- 
 scopes continue, and all such should be encouraged (provided great care 
 is exercised) because all effort results in increased attention to the 
 esophagus and its diseases. There is absolutely no hope that any eso- 
 ])hageal instrument will ever lie devised that will be safe unless carefully 
 used, because even the soft rubber stomach tube has been known to cause 
 fatal perfor.-ition. ( )ne of the most successful of the angular esophago-
 
 14 
 
 INSTRUMENTS. 
 
 Fig. 4. Briinings' spatulae and tubes for use with the illuminating handles 
 shown in the preceding illustration. A, tube to be attncbed to hanaie. B, ninci' 
 tube sliding into A, as shown at C, the inner tube being locked at the required 
 depth by the ratchet shown at D. The other illustrations are laryngeal spatulae. 
 
 Fi... 
 duction. 
 
 \ ^\ \ 5\ \ -\ \ '\ \ A \ -\ \ -\ \ -\ \ "V \ A \ "V^W^.^ 
 
 t 
 
 s> 
 
 2) 
 
 Moshcr's e^ophaposcopc sliowing distal light and mandrin for intro-
 
 IN'STRUMEN'i'S. 
 
 15 
 
 scopes is the indirect one of Lewisohn. The author saw it passetl upon 
 a patient with practically no discomfort and the view was good. In its 
 present form it is, of course, adapted to sim])le inspection, not for the 
 
 I 
 
 ^^f^ 
 
 1 ■ • • I • . • I ■ • ■ • I ■ ■ • ■ I ■ ■ ■ ■ I ' • • ' ■ .' ■ ■ 
 
 m^ 
 
 -(^^ 
 
 Fk;, (). Giiisiz's e.<cii)liai;oscoiit, (luiscz, as .shown in the imner iUii'trjition. 
 uses a Claar headlight for illumination and a soft-ended inandiin for introduction 
 as shown in tlie Icjwer illustration. 
 
 removal of foreign bodies or sjiecimens, nor for prcihing or palpation, 
 wi])ing or medication. 
 
 A nimilicr of laryngeal specvdae have been di\ised. Ingals' (Fig. 
 1), Hill's (Fig. 9), Dickinson's (Fig. 13), and I'ratt's use a dis-
 
 16 
 
 IXSTRUMEXTS. 
 
 tal light. Pratt's has a battery contained in the handle Richartl H. 
 Johnston prefers a narrow tube and has done wonderful work with the 
 author's original tubular speculum (Fig. (i, p. 19, of the earlier book, 
 IJib. 2()9). Johnston attached a handle as shown in Fig. 11. Mosher 
 devised an open speculum for use with the headlight or head mirror, 
 Fig. 12. The Boyce speculum is (]uite simple and eflfective when used 
 with the Wendell C. Phillips headlight, worn between the eyes, w-here 
 the luminous and visual axes almost correspond. 
 
 THE AUTHORS IXSTRUMEXTS. 
 
 LaiyHf/oscof^cs. The laryngeal speculum or direct lar}-ngoscope 
 (Fig. 14) devised by the author in 1903 and shown in Fig. 7 of the 
 
 Fig. ". Yankauer's laryngeal tube-spatula. 
 
 earlier book (P)ib. 2()9) has been found to answer all requirements for 
 direct laryngoscopv so well that the atuhor has made no modifications, 
 excejjt that, at the suggestion of R. H. Johnston the handle is now made 
 detachable. This instrument has received various names : laryngeal 
 speculum, slide speculum, direct laryngoscope, etc. Being us.ed for ex- 
 .amination of the larynx, it would seem that the now generally used 
 term "lan^ngoscope" is preferable. The method of introducing broncho- 
 scopes through this laryngoscope has the great advantage that nc> septic 
 instrument need be introduced into the trachea, because, as abundantly 
 proven by laljoratory examinations of secretions withdrawn from the 
 bronchi through the bronchoscope, the bronchoscope need not be con- 
 taminated in introduction. Laboratory work has shown that there is, 
 under normal conditions, a sharp line of limitation of oral sepsis at the
 
 INSTRUMRNTS. 
 
 17 
 
 orifice of the larynx. The first form of laryngoscope used by the author 
 was modeled after the original Kirstein ''autoscope" which had its trans- 
 verse greater than its vertical diameter. A double handle was attached 
 to a simple oval tube with half its periphery cut away for the distal two- 
 thirds of its length (Fig. 15). Then, after Killian created hronchoscopv, 
 the author added a slide at the side for bronchoscopy. Pioth of these 
 
 Fig. 8. Kaliler panelectroscolie. The tulics used with this arc similar to the 
 sliding tubes of Briinings. The rays of light from the lamp, h, are rcHccted by the 
 mirror, g, into the tulie, e. The endnscopist's eye is placed at the notch in the 
 mirror, g. The mirror can be thrown out of the way for the introduction of in- 
 struments hy pressure of the tluimli on the arm, c. 
 
 laryngoscopes were used with the ordinar_\- head-mirror, and witli the 
 Wendell C. Phillips head-lamp worn between the eyes. As the author 
 found the oval lumen less convenient than the round for working at the 
 side instead of over the dorsum fif the tongue, as he fre(|ucntlv wished 
 to do. he abandoned the n\al lumen for the niund lumen with the slide
 
 18 
 
 INSTRUMENTS. 
 
 Fig. 9. Hill's modification of the Chevalier Jackson laryngoscope. 
 
 3Q CCHVMCTRCS ->i 
 
 Fig. 10. Hill's esophagoscopc. 
 
 Fig. II. The author's tubular speculum to which Dr. Richard H. Johnston 
 added the laryngoscope detachable handle (A), preferring this narrow tube to the 
 wider laryngoscope tube. At the left Dr. Johnston is using the tubular speculum 
 with handle detached, the patient being in the straight position, witliout extenson 
 of the head.
 
 INSTRL'MKNTS. 
 
 19 
 
 at the side. As the edges of tlie shde were then made the\' became rough 
 in use, and to {jrevent this the sHde was moved to the top and in tliis 
 form, witli the addition of the light carrier of the Einliorn esoi)hagoscope, 
 it has been in general use ever since. Recently some men who have done 
 the author the honor to work with him ha\e found the oval model so 
 
 Fig. 12. Mosher's laryngeal spatula with dental protector. 
 
 Fig. i.v Ij. M. Dickinson's larynKOSCopc. 
 
 convenient for the introduction of esoi)hagosco])es. lironchoscopes, and 
 es[)ecially intratracheal insufflation tubes, that it has iieen deemed worth 
 while to re-urrert the o\al mnikl. Tlu- .slide can be left off altogether 
 and thus removal of the laryngcjscojie after introduction of tubes of all 
 kinds is facilitated, as in the Dickinsun siieculum. The o\al lumen, 
 giving a larger fiel.d. has the additional advantage of facilitating the
 
 20 
 
 I.NSl'KL'.MHiN'TS. 
 
 identifications of land-marks and of affording more room for endo- 
 laryngeal operations. Probably many operators will prefer working 
 through the oval laryngoscope to the method that has seemed easiest to 
 me: namely, using the round lumen laryngoscope for vision only, the 
 forceps and other instruments being passed alongside the laryngoscope. 
 
 The width of the oval lumen laryngoscope will be found greatly to 
 increase the difticulty of exposing the anterior commissure. Everything 
 considered, the regular laryngoscope (Fig. 14) will be found preferable. 
 
 I 
 
 
 J 
 
 Fig. 14. Author's separable speculum for passing bronchoscupes and lor di- 
 rect laryngoscopy. This instrument, also called "direct laryngoscope," laryngeal 
 speculum, etc., has been found perfectly satisfactory without modilication in 
 size or shape. Two sizes are needed, one for adults and one for children. The au- 
 thor personally never used the handle, A. B., in the child's size instrument, (sub- 
 stituting a hooked end) because he always examines children recumbent. For endos- 
 copists who use the sitting position for children the handle is a great advantage. 
 A number of modifications have been made by varioua endoscopists to suit their 
 individual requirements. (Illustration reproduced from the author's earlier volume.*) 
 
 Bronchoscopes. In bronchoscopes the author has been unable to im- 
 prove on the light, simple, well-illuminated instrument shown in Fig. 1(>. 
 His only failures to remove foreign bodies from the bronchi since com- 
 mencing to use this instrument a number of years ago, were due to fail- 
 ures to find four pins which were in minute bronchi beyond the limits 
 reachable by a 1 mm. tube, in other words, beyond the limits of bronchos- 
 copy. In no instance has this bronchoscope been found wanting. 
 
 Four sizes are sufficient for every possible case from a new-born in- 
 fant to the largest adult. 
 
 •Tracheo-bronchoscopy, Esophagoscopy .and Gastroscopy. PubUshed at St. 
 Louis, 1907.
 
 IXSTRUMKNTS. 
 
 21 
 
 The selection of a tube for the particular case no longer presents the 
 difficulties that it did when a large number of tubes of various lengths 
 were thought to be necessary. The bronchoscopes and esophagoscopes 
 can, as a rule, be selected absolutely by the ages mentioned in the given 
 list. Naturally there is a border-line between the older child and the 
 young adult, where a slightly larger size than the child's size could be 
 used where the adult instruments are slightly too large. In the case of 
 the bronchoscope, this field is fully covered by the 7 mm. instrument, 
 which can be used in such cases, and is plenty large enough for work in 
 an adult also, though for adults of average-sized larynx and trachea it is 
 much better to have the !1 mm. bronchoscope, as it gives a much larger 
 
 Fig, 15. Form of the first of the author's laryngoscopes originally used with 
 the Wendell C. Thillips headlight. Here shown with Einhorn li.ght carrier add- 
 ed. The slide at the side can he left off altogether, if desired, to facilitate the re- 
 moval of the laryngoscope after the insertion of Ijronchoscopes, intratracheal in- 
 sufflation anesthesia catheters, etc. The instrument shown in Fig. 14 is prcfcralile. 
 
 field of view. In cases where it is desired to enter a ver)- small branch 
 bronchus, low down, it would be necessary to use the 7x10 bronchoscope 
 in an adult. In children under one year of age the T) mm. bronchoscope, 
 is used by many .American bronchoscopists, but as it does not 
 ordinarily go through easily, some traumatism may be done to 
 the lar>nx which will result afterward in subglottic edema. The 
 author and Dr. b.lkn J. Patterson always use, in such cases, 4 mm. 
 bronchoscojies, through the mouth ; but to those who have not practiced 
 work with small tubes, this may ])rove rather difficult. From one to five 
 years of age, a ") mm. l)ronchoscope will be found perfectly satisfactory 
 for use through tl;e larynx. .\t six years of age and over, the 7 mm.
 
 INSTKUMHNTS. 
 
 bronchoscope can be used through the larynx without risk of subglottic 
 edema, if none has existed prior to the bronchoscopy, and if manipula- 
 tions be gentle. 
 
 ^ 
 
 Fig. i6. Author's lircmchoscope as originally devised. The author has had 
 adried to this the small hranch tube suggested by T. Drysdale Buchanan. (Fig. 
 17). The slanted tulie mouth gives a lip that not only facilitates introduction, but 
 has manifold uses. All of the author's tubes are fitted with "cold" lamps, which 
 lie in a recess out of harm's way and out of the line of vision, .\spirating canals 
 were found occasionally useful before the author developed his "sponge-pumping" 
 method of removing secretions. 
 
 r^ 
 
 Fig. 17. Dosimetric anesthetizing attachment for the bronchoscope. Devised 
 by Dr. T. Drysdale Buchanan. The small branch tube ends in the lumen of the 
 bronchoscope, and not in an auxiliary canal. All of the author's bronchoscopes are 
 now made with this small liranch tube, as it has been found very useful for bron- 
 choscopic oxygen insutTlation. 
 
 If inslnimcnts are selected by the tjiven suggestions, as to sizes, there 
 will nexx'r be any nee<l for withdraw ing one bronchoscope and replacing it 
 with a different size. Should there be any trouble with the lamp, which 
 shfjuld not occur more than once or twice in a hundred bronchoscopies,
 
 IXSTRUMKNTS. 
 
 23 
 
 the lamp can be withdrawn with the hght carrier and replaced by a new 
 one, without removing the bronchoscope. With the proper use of the 
 sponges shown in Fig. ■<;T. the light carrier never need be withdrawn for 
 the purpose of cleaning the lamp, as the sponges wipe the lamp clean at 
 the same time that they are used for removing secretions from the field 
 of vision, as shown in Fig. 25. One of the author's assistants has called 
 attention to the fact that it was unnecessary to remove a light carrier 
 once in 72 consecutive cases. Secretions never bake on the lamp because 
 the lamp does not get hot. The lamp is in a recess out of the way of 
 instruments, so that it cannot be broken and cannot get caught on sponges. 
 The objections raised by operators who have never used distal illu- 
 mination are unjust. One statement made thai the distal light is quickly 
 
 Fig. iS. Author's special small-ended liionclioscope for examining the ori- 
 fices of very small bronchi. Xot intended for regular work upon ordinary cases. 
 
 obscured by blood and secretions is based ])iuely on theory. The author, 
 as is well known by all who have honored his clinic wilii a visit, works 
 for hours at a time without one moment's interruption for removal or 
 cleansing of lamps other than the regular swabbing that is necessary for 
 the remow'il of secretion from tlie field with any fnnn of illumination, it 
 is impossible lo see, with any form of instrument, ihrotigh a pool of se- 
 cretions. 
 
 Bsophagoscopes. The author has m;ide no changes whatever in the 
 esophagosco])e devised by iiiin in 11M)1. lie has, however, abandoned the 
 use of the mandrin altogether, the instrument being always passed by 
 sight and the matnirin is never used unless it is desired to hold it on the 
 outside of a ])atient to determine the point on the surface corresponding 
 lo the dei)th of insertion of the tube. For this ])urpose, the mandrin gives
 
 24 
 
 INSTRUMENTS. 
 
 the exact length of the esophagoscope, and by holding it parallel to the 
 esophagoscope, as indicated by the portion of the esophagoscope not yet 
 inserted, a point can be found on the skin-surface of the chest or epi- 
 gastrium that will correspond precisely to the distal end of the esophago- 
 scope. The esophagoscope is always passed by sight, absolutely never 
 any other way, for the following reasons: 1. Once the knack is ac- 
 quired, it is just as easy to pass by sight. 2. In foreign-body cases, if a 
 mandrin be used the foreign body, if small, is very apt to be overridden 
 before the operator realizes that the distal end has reached the position 
 
 Fig. 19. The author's esophagoscope and gastroscope with distal light and 
 drainage canal. An obturator is provided but is never used by the author. Only 
 two sizes are needed. 10 mm. x 53 cm. for adults. 7 mm. x 45 cm. for children. 
 Shorter sizes are made but are not used by the author because with the distal light 
 there is no advantage in a short tube. This esophagoscope has been in constant use 
 for 10 years and has been found to be in every way satisfactory without modifica- 
 tion. The slanted end added (Fig. 426), for special purposes, facilitates introduc- 
 tion. 
 
 Fig. 20. Window-plug for occluding the proximal tube-mouth when it is de- 
 sired to balloon the esophagus or stomach, as su,ggested by Mosher. 
 
 of the foreign body. 3. There may be in any case, lesions of the eso- 
 phagus that can be seen and avoided, provided the instrument is being 
 passed by sight. 4. The importance of the use of the open tube passed 
 by sight in foreign-body extractions is so great that it is important that 
 all esophagoscopies should be done in that manner, in order that skill 
 may be ac(|uired, so that when foreign-body cases are met with, the pass- 
 age by sight will be easy. If this knack is not acquired, it is very much 
 more difticult to pass by sight than with a mandrin.
 
 INSTRUMENTS. 25 
 
 An esophagoscope willi a slanted end similar to the bronchoscope 
 (Fig. IG), is useful for finding the subdiverticular opening, and for solv- 
 ing some of the mechanical problems of foreign-body extraction. It has 
 no holes in the side and is longer and larger in diameter than the bnmcho- 
 scope. (Fig. -J2(i). 
 
 Complicated forms of tubes with extracting, excising, and dilating 
 attachments have not seemed to the author as generally applicable as plain 
 tubes through which, by manual manipulations, any procedure can be 
 carried out with appropriate, independent instruments. 
 
 Measuring rule. It is customary with esophagoscopists to measure 
 distance from the upper teeth. Some esophagoscopcs have graduations 
 marked on the outside. The author's tubes are too thin and light for this, 
 and moreover, a smooth exterior is a great advantage. Therefore, he 
 uses a 2") cm. steel rule, (^obtainable at any machinist's supply house), 
 
 r 
 
 i-,i^^ 
 
 } 
 
 '^ 
 
 Fig. 21. Esophageal speciihim for foreign l)ody work and for operations upon 
 the upper end of the esophagus. This instrument, by detaching the handle, becomes 
 a very efficient pleuroscope because of the facility with which tlie flopping lung can 
 be controlled. It can be thoroughly sterilized. The child's size is an excellent 
 laryngoscope and subglottic laryngoscope for adults. 
 
 which is sterilized with the instruments and kept on the sterile instru- 
 ment table. When the tube-mouth is at the lesion, an assistant places one 
 end of the rule at the upper teeth (or alveolus if teeth are absent) and the 
 distance to the proximal end of the esophagoscope is marked by holding 
 the thumb at the i)oint. The measurement is subtracted from the known 
 tube length. Thus, wdien 20 cm. of the 5:? cm. esophagoscope projects 
 proximally from the teeth the lesion is known to be 'M cm. from the U])- 
 per teeth. If it is desired to locate this point externally on the patient's 
 chest after the esophagoscope is withdrawn, the patient sitting erect is 
 told to look at the ceiling and the 23 cm. is measured downward from 
 the upper teeth, and a mark is made on the skin of the client. The same 
 method is used in bronchoscopy.
 
 2() INSTRUMENTS. 
 
 Esophageal speculum. For dealing with foreign bodies and disease 
 high up in the esophagus, the author has found an elongation of his 
 laryngeal speculum exceedingly useful. This instrument is 25 cm. long 
 for use in adults. K! cm. for children, and with these instrimients there 
 is very much less risk of overriding foreign bodies in the high situation 
 than with the esophagoscope. This esophageal speculum has also been 
 found particularly useful for the breaking up of those rare congenital 
 webs first described by Mosher and Clark, and of the high strictures of 
 the esophagus following decubitus idcers resulting from the mixed infec- 
 tions complicating enteric fever, scarlatina, diphtheria and like conditions, 
 and those following gummata. These webs and strictures yield 
 quite readily to the breaking up and stretching with this speculum. 
 Cicatricial stenoses, especially those following the breaking down of gum- 
 mata, have a tendency to recur, and it is necessary to repeat the treat- 
 ment frequently, but in some of the conditions a very few treatments are 
 sufficient, a divulser being occasionally reciuired. Intricate instrumenta- 
 tion, when needed, is greatlv facilitated by the wide exposure afforded. 
 
 In foreign body work it has seemed to the author to be preferable 
 to an esophagoscope for the removal of foreign bodies at their favorite 
 site of lodgment just above the upper thoracic aperture. Foreign bodies 
 in this location are much more apt to be overridden by the esophagoscope 
 than by this speculum. Of course at the mouth of the esophagus, the 
 cricopharyngeus, coming out from the posterior wall, has a tendency to ob- 
 struct the view : and this must be repressed posteriorly bv an elongated 
 Mosher alligator forceps. (Plate III, Fig. 10.) The speculum can be 
 used in either the recumbent or the sitting position of the patient. It is 
 made in two sizes, one for adults and one for children. The child's size 
 makes an excellent adult laryngoscope, especially for those who prefer 
 a narrow spatular end. It also makes an excellent subglottic laryngo- 
 scope for adults, as the relatively narrow spatular end can be readilv in- 
 serted through the glottic chink. 
 
 Batteries. Xo practical eft'ort has yet Ijeen made to ada]jt the tallow 
 candle or a kerosene lamp to endoscopy. We are compelled to use elec- 
 tric light of some kind. If the endoscopist is not of a sufficiently mechan- 
 ical turn of mind to keep his electric lights burning properly, no matter 
 what form of instrument he uses, he will not have the greatest success in 
 foreign-body work, for endoscopic extraction is a ([uestion of mechanics 
 from beginning to end. It does not require great brain power or high in- 
 tellect, but in some cases mechanical ingenuity is taxed to the utmost to 
 get out the foreign body without interfering with breathing and without 
 traumatism to the tissues. If the surgeon is not a mechanical genius, he 
 should have a trained surgical assistant who has the necessarv mechanical
 
 INSTKUMEXTS. 
 
 27 
 
 ability. The sim|)lest, best and safest source of current is a double dry 
 batter}' arranged in two groups of four cells each. Each set should have 
 two liinding posts and a rheostat. I'ailure will result from an attempt to 
 work with makeshift batteries, the current from which, with onlv a cell 
 selector for control, jumps up from underillumination to overillumination 
 and burns out the lamps. Ingals, who is a leading authority on bronchos- 
 copy, and the author concur in the lielief that all forms of rheostats 
 devised for adapting commercial circuits to tube work involve a certain 
 degree of risk because of the tube which makes a moist contact with 
 tissues so close to more or less of the course of tb.e vagi. .\o matter how 
 
 Fig. 22. Author's endoscopic battery heavily built lor rclialiility. It contains 8 
 -dry ce^ls, series-connected in 2 groups of 4 cells eacli. ICacli group has its own 
 rheostat and i)air of binding posts. 
 
 tliorough the construction, lliere is always a jiossiliility of "grounding of 
 the circuit through the handle, tube, and jiatient. This danger is present, 
 whether the lighting is proximally or distally a|)plied. These remarks <lo 
 not api)ly, of course, to the Kirslein lamp such as was originally used by 
 Killian, and such as he still uses for all work other than demonstration. 
 Tills lamp, being on the forehead of the operator, there is no chance of the 
 current being communicated to the bronchoscope or esophagoscojic. The 
 O[)crator may. at times, get a portion of the current on his head, but tliis 
 being on the skin surface is of no consequence, and is a \ery different 
 matter from the long moist contact of large area throughout nearly the 
 full length of both vagi. The author is delighted to have the support of 
 so eminent an authority as Ingals. ( I'ib. 'Z'H\). The atithor's objection has
 
 28 INSTRUMICNTS. 
 
 been altogether theoretical, but Ingals has actually seen the sparking due 
 to "short circuiting." The author has always used batteries and has 
 found them quite satisfactory. All operators who have had any trouble 
 with batteries have been working with an equipment that is not of sub- 
 stantial character. Tn his early days, the author had much trouble with 
 batteries which were made in the same flimsy manner as the ignition sys- 
 tem of the early automobiles. In the latter, freedom from trouble only 
 came with heavy solid construction. With this in view, the author had 
 built by Mr. Mueller, a substantial battery, the construction of which 
 should be beyond failure. (Fig. 22). It contains two sets of four cells 
 each of the ordinary dry battery, which can be obtained anywhere, day or 
 night, Sundays and holidays, at any garage. It is free from the objection 
 to the storage battery that, once exhausted, requires a number of hours 
 for recharging. It takes but a moment to put in new cells. Dr. Ellen J. 
 Patterson and the author have two of these batteries and in an experi- 
 ence of thousands of cases, they have never yet failed to obtain a light, 
 nor has any bronchoscopy, esophagoscopy, or direct laryngoscopy failed 
 or been delayed for w-ant of illumination. The cells are changed once 
 every three months without waiting for them to deteriorate. Small, 
 flimsy batteries, and especially pocket batteries are a delusion and a snare, 
 and their use for endoscopy is an injustice to the patient. \\'here the 
 speculum is used solely for direct laryngoscopy, or in the introduction of 
 silk-woven insufl^lation catheters which are non-conductors the author 
 believes that the tise of commercial circuits with good rheostats is harm- 
 less, because the small area of contact at the base of the tongue involves 
 no serious risk, but personally he prefers batteries. 
 
 Aspirators. Many new forms of aspirators have been devised. For 
 the removal of secretions Yankauer has perfected an aspirator operated 
 by a small exhaust-fan in connection with an electric motor. He has al- 
 so used a jet of compressed air blowing sidewise across the proximal 
 tube-mouth to blow away the secretions coughed out by the patient to 
 prevent them soiling the mirror of the Briinings lamp or Kirstein head- 
 light, and to prevent them reaching the endoscopist's face. Ingals uses 
 an electric aspirating pump originally devised for massage of the ear. A 
 number of endoscopists are using various forms of aspirators attached to a 
 water- faucet. In using these, it is necessary to exercise precaution if com- 
 mercial circuits are used for illumination, lest the current be "grounded" 
 through the water pipes, especially when withdrawing long asjiirating 
 tubes. The author [^refers, for esophagoscopy, an aspirating canal in the 
 wall of the esophagoscope or gastroscope, the exhaust being by an as- 
 [lirating syrmge. (Fig. 23.) The jiositive pressure-side of the syringe 
 also has a soft rubber tube, and in case the aspirating c;mal in the wall
 
 IXSTRUMKNTS. 
 
 20 
 
 of the esophagoscope becomes obstructed, a change of the soft rubber 
 tube from the negative pressure to the positive pressure will force out 
 any clots or other obstructions which may have entered the canal. Con- 
 trary to many of the statements that have appeared, the form of aspira- 
 tion used by the author has absolutely nothing to do with distal illumina- 
 tion. There is no form of illumination that will enable the operator to 
 see through a pool of blood and secretion. How to remove the fluid in 
 the least possible time is the study of all endoscopists, and the aspirator 
 
 Fig. 23. Aspirator for esophagoscopy with additional tube connected with the 
 plus pressure side for use in case of occlusion of the esophageal drainage tube. 
 This aspirator is much more efficient than any soft rubber-ball aspirator can pos- 
 sibly be. 
 
 Fig. 24. Nozzle fur attaching to the aspirator, for freeing the fauces and 
 pharynx from secretion which otherwise would overflow into the larynx in peroral 
 endoscopy, because the patient cannot swallow while endoscopic tubes are in place. 
 
 in the wall of the esophagoscope is used because there is no inlerrui)tion 
 of the work. It is a common thing at a gastroscopy to reinove a pint of 
 fluid without any interruption. An asi)irating canal in the tube-wall can 
 never become occluded by the indrawing of the mucosa as happens with 
 an inserted independent tube, sometimes thus injuring the indrawn mu- 
 cosa as well as occluding the aspirating tube. One great advantage of 
 the syringe form of aspirator is its simi)licity and portability. Most of 
 the authiir's work has been done at tiie fourteen hospitals of Pittsburgh, 
 and i)ortability of the entire instrumentarium and organization made 
 work in each as convenient as if all work had been done in one institu- 
 tion.
 
 30 
 
 INSTRUMEXTS. 
 
 If the patient is being annoyed with secretions overflowing from the 
 pharynx into the larynx in the recumbent position, the soft rubber as- 
 pirator tubing is detached from the esophagoscope and attached to the 
 curved metal tube (Fig. 24), which is hooked over the upper alveokis 
 (recumbent patient) and the pharyngeal secretions thus aspirated. 
 
 The author does not use any form of aspirator, either in the wall of 
 the tube or otherwise in the bronchoscope. He has found that the best 
 of all ways to remove abundant secretions and blood during bronchoscopy 
 is to insert a large swab on the usual long Coolidge sponge-carrier, push- 
 ing it down until the large gauze sponge goes beyond the distal end of 
 
 S.^---/.: :.:..::: 
 
 ■i-'Mi. 
 
 Sl^:^:: 
 
 B 
 
 Fig. 25. Sponge carrier with long collar for carrying the small sponges shown 
 in Fig. 27. The collar screws down as in the Coolidge cotton carrier. About a 
 dozen of these are needed and they should all be small enough to go through the 4 
 mm. (diameter) bronchoscope and long enough to reach through the 53 cm. (lengtlO 
 esophagoscope, so that one set will do for all tubes. The schema shows method of 
 sponging, The carrier C, armed with the sponge, S, when rotated as shown by the 
 dart, D, wipes the field, P, at the same time wiping the lamp, L. The lamp does 
 not need ever to be withdrawn for cleaning during bronchoscopy. It is protected 
 in a recess so that it does not catch in the sponges. 
 
 the bronchoscope. Then the i)ationt will cough the bronchoscope full of 
 the fluid, and the withdrawal of the carrier and swab will pull up often 
 as much as an entire tube full of secretions at a time, just as the jilunger 
 of an ordinary pump will lift the water which is above the plunger. This 
 is one of the advantages in working tmder slight anesthesia or none at 
 all. This method of aspiration in a case of bronchoscopy with profuse 
 secretion may seem to the bystander to be less efficient than would be some 
 form of ptimp, but it must be remembered that there is no great pool of 
 secretion which can be completely and permanently emptied. The secre- 
 tion is constantly being brought up from the brcjnchioles by the continued
 
 INSTRUMENTS. 
 
 31 
 
 coughing efforts and must hi: removed intermittently from time to time 
 as it is brought up to the neighborhood of the ihstal end of the tube. The 
 effect of the sponge is to cause a fresh cough and to bring up more se- 
 cretion to tlie point where it can be reached. Thus the continued swab- 
 bing with the gauze sponges removes not only the secretion which is al- 
 ready in the bronchus which is being explored, but it results in the re- 
 moval of all the secretions from the minute bronchi, thus soon resulting 
 in a relati\elv drv field. 
 
 
 5 
 
 7 
 
 qand 10 
 
 ... A . _. 
 
 f4fb 
 
 4 mm. 
 
 Tubes. 
 
 Fig. 26. Exact size to wliich the bandage-gauze is cut to make tiuloscopic 
 sponges. ICach rectangle is the size for the tulial diameter given. The dimensions 
 of the respective rectangles are not given because it is easier lor the nurse or any- 
 one to cut a cardboard pattern of each size directly from this drawing. Tlie gauze 
 rectangles are folded up endwise as shown at .-\, then once in the middle as at B, 
 then strung one dozen on a safety pin. In America gauze bandages run aliout 16 
 threads to the centimeter. Different material might require a slightly different size 
 and the pattern could be made to suit. 
 
 Sponge carrier. The author has lengthened the collar of the Cool- 
 idge cotton carrier so tliat the collar never catches on the distal end of 
 the bronchoscojie or esophagoscope on withdrawal of the sponge holder, 
 because the collar is too long for its proximal end to get beyond the tube- 
 mouth. The author uses in this holder the small folded sponges shown 
 in Fig. 27.
 
 32 tNSTRUMENTS. 
 
 Sponges. Small squares cut from a gauze roller bandage (ordinary 
 surgical gauze is too large in the mesh) and folded into little pads and 
 strung onto a safety-pin, as shown in Fig. 37, before sterilizing. These 
 are prepared beforehand like any other operating room supplies, packed 
 sterile, and kept in readiness. Four sizes are needed for the different 
 tubes and they are numbered on the outside of the packages 4. 5, T, 10. 
 They are held securely in the sponge carrier shown in Fig. 25. 
 
 h'oreign-hody forceps Years of experience have demonstrated that 
 for foreign-body work in the larynx an alligator forceps with roughened 
 jaws, known in America as Mosher's, in Great Britain as Paterson's, and 
 in Germany and France as Mathieu's forceps, serve every purpose. 
 Mathieu's is longer than the others and hence is better adapted to use 
 through the esophageal speculum. 
 
 Experience has continued to demonstrate the fact that there is no 
 form of forceps that has the power and the strength against breakage 
 that pertains to the tube forceps. Hinged-jaw forceps are weakest at the 
 
 Fig. 2/. Manner of keeping endoscopic sponges. About a dozen of one size are 
 transfixed on a safety pin, wrapped, the size marked on the wrapper, and then ster- 
 ilized, to be opened onl_v as needed. About 5 dozen sponges of each of the 4 sizes 
 should be kept on hand. Only one sponge is placed in the sponge-carrier at a time. 
 These sponges are made for the author by Messrs. Johnston and Johnston, of Xew 
 Brunswick, X'. J., and are known as "bronchoscopic sponges." 
 
 rivet and do not begin to have the strength of grip, nor the strength 
 against breakage when the forceps of necessity is long and slender, as in 
 bronchoscopy and esophagoscopy, though for the larynx where a short 
 and relatively heavy and rigid instrument is required, the alligator-jaw 
 fulfills all purposes. 
 
 Instrument-tnakers. either through carelessness, or more likely from 
 the taking of a later and still later instrument as a model, drift farther 
 and farther away from the original design, so that very often the devisor 
 of an instrument can scarcely recognize it when it comes to hand. In 
 some instances forceps are made so far wrong that they will not go in 
 the bronchoscope. More often the errors are in the little details, such as 
 the serrations of forceps. Killian in his early forceps, such as the 
 "bean" forceps (Fig. 32). especially designed the serrations to have a 
 cant backward so as to make the forceps easy to push down over a for-
 
 in>'i'iu'MI';nts. 
 
 33 
 
 cign body but lo grip firmly on witlidiawal. Copying al'lcr Killian. ibc 
 author's early forceps were all tluis made ; but instrument makers have 
 drifted away from the original model until now they are turned out with 
 evenly notched serrations that are very smooth on the top edges instead 
 of being sharp and canted as show^n in Fig. oU. The shape of serrations 
 and their action can be readily understood by looking at the lower feed 
 mechanism of any sewing machine or the gripping-jaw of any pipe- 
 wrench. Such forceps, however, are capable of much traumatism if 
 carelessly used, and under no circumstances whatever should such a for- 
 ceps be placed blindlv into a bronchus which is so small that the closure 
 
 Fig. 2S. .\iithur's universal handlL' with nut- furm of forcign-lHuly jaws at- 
 tached. Tills handle mecliani.sm is so simple and delicate that the most extinisite 
 delicacy of touch is jiossible. Unfortunately, instrument makers have often omitted 
 the little tliumli nut indicated ahove, with the result that the stylet was pulled 
 through when strong traction was made. The cannulae are 45 cm. and 60 cm. long. 
 There is a smaller size made for infant use, just half of the dimensions except 
 those of tlie handle. 
 
 of llic forceps cannot be watclied. ll blind groping in a .--niall broiKlius 
 is ever justiliable. it is oiil\ so willi forceps whose serrations arc rounded 
 and not canted. The author prefers all inslrunients, and especially fnr- 
 ceps. in the lightest ])ossible form consistent with the amount of strength 
 necessary plus a sunicii-ni factor of safety, b'urthermore, for lightness of 
 touch it is absolutely necessary to dispense with springs to throw the 
 forcei)S open. A si)riiig-opi)osed forceps cannot possibly communicate to 
 the fingers the lightness of tomb which is essential. For general work, 
 the author has never found anyliiing better than the forceps illustrated 
 in his first work on bronchoscopy ( I'.ib. 2iiiM. The ring handles do away
 
 34 INSTRUMENTS. 
 
 with the necessity for opening springs. These forceps enable exceeding 
 Hghtness of touch by which one can easily tell if the foreign body is prop- 
 erly grasped, and also enable the endoscopist to gauge precisely the de- 
 gree of pressure that can be applied without crushing the foreign body in 
 the case of friable bodies. 
 
 The selection of the forceps for use in a particular case is a very 
 important matter and concerns the mechanical problems very closely. In 
 
 Fig. 29. Side-curved jaws for the author's forceps. Reproduced here to em- 
 phasize their usefulness. (Bih. 269.) 
 
 Fig. 30. Enlarged view of the author's foreign-body jaws, showing proper 
 slant of serrations to prevent slipping. This slant is often lacking in the instru- 
 ments in the shops. 
 
 Fig. 31. Schema showing test of author's forceps. If properly adjusted, the 
 point of the jaws of the forceps, F, w^ill pick up the epithehum and elevate the skin 
 from the palm of the hand (S) held vertically in contact with the point of the 
 forceps jaws, when traction is made. This shows that the jaws come together first 
 at the point in closing. 
 
 Fig. 32. Killian's "bean forceps" showing the cant of the serrations to prevent 
 slipping which should be on all foreign-body forceps. The fenestra are to lessen 
 the tendency to crush friable bodies like beans. 
 
 most instances, however, the plain jaw-forceps with canted serrations 
 shown in Fig. 28, will serve everj' purpose. Almost equally 
 useful is the side-curved forceps shown in Fig. 29, and if the author were 
 limited to a single forceps, it would be this side-curved form (Fig. 29). 
 The jaws projecting sidewise are easily seen closing. .\ large proportion 
 of the successful foreign-body extractions by the author have been done
 
 INSTRUMENTS. 35 
 
 with these two forms of jaws. The exceptions to their use are when 
 the foreign body must be turned in order to make the proper points pre- 
 sent themselves. In the case of pins and needles, the side-curved for- 
 ceps can always be used to cause presentation of the foreign body in the 
 proper axis for removal. With irregular objects, however, having one 
 point sharp such as angular pieces of bone, it is very necessary to disen- 
 gage the foreign body near the point with a forceps that will permit rota- 
 tion ; and for this puq)ose, the rotation forceps shown in Fig. 33 are 
 ideal, because the points will hold firmly, yet will permit the foreign body 
 to turn in the direction of least resistance. In another class of cases they 
 can be made to throw the point out from the wall and into the mouth 
 of the tube where the point is shielded from doing damage to the tracheal 
 or esophageal wall, as will be explained in connection with the mechanical 
 problems of brpnchoscopic and esophagoscopic extraction of foreign bod- 
 ies. The author has a separate handle for each forceps in order that not 
 a moment may be lost in changing handles at a critical moment, should a 
 different form of jaw be required. The jaws can be adjusted at any 
 angle, but it is the author's practice always to have them open in an up 
 and down direction, and when other directions are needed, the forceps' 
 handles are turned in the |)njijer way ; thus a certain co-ordination and 
 nerve-cell habit is established by which the operator always knows in 
 which direction the jaws are opening. This facilitates promptness in the 
 ocular endoscopic recognition of the jaw movement, because the observ- 
 er knows for what to look. The curved-jaw forceps should always have 
 the curve to the left of the ojjerator. as this is the most convenient posi- 
 tion in which to observe the jaws close and to guide their w'ork with the 
 eye. I'n fortunately, many instruments were turned out by various 
 manufacturers labeled with the author's name which were heavily con- 
 structed, having tile jaws of poor lcnii)cr and without the very essential 
 little thumb nut, iMg. 2S. This omission may have been ])artly due to the 
 fact that it was not shown clearly on the early illustrations. This thumb 
 nut i)ermits the o|)crator to exert great jiower without any danger of the 
 jaw-stem pulling through. The screws at the side are still used in order 
 to lock the jaw-slom so that it will push forward for opening the jaws. 
 Another misfortune is the fad that many of these instruments are very 
 clumsily manufactured. The author uses two different strengths of for- 
 ceps, the one reasonably heavy for use through all except the very small- 
 est tubes. For the infant bronchoscopes, very lightly constructed for- 
 ceps are used because great strength is not necessary. It is necessary to 
 see the forceps close, and fur this very slender forceps are required. 
 They are just half the strength and half the size, in all dimensions, of the 
 regular forcejis, except that the handle is the regular size. They are 45 
 cm. in length of cannula.
 
 3G 
 
 IXSTRL'MKXTS. 
 
 Occasionally, it is desired to twist a foreign Ixnly. The regular for- 
 ceps will be found to give all the rotatory force that it is safe to use. 
 If excessive twisting movement is to be applied, use may be made of 
 the author's forcc]-s with S(|uare cannula, into whicli the stiletto, also 
 squared, works at a good easy fit, yet will not spring. 
 
 For cutting in two of pins, wires and the like, Casselberry's forceps. 
 Fig. o-J, are excellent. Before using, howexer, it is well to test the.n 
 on a pin similar to the one in the patient, because if not correctlv made 
 thev will not hold the fragments. 
 
 Fig- 33- Pointed jaws for the author's forceps. Useful wlien it is ilesired to 
 permit turning of a foreign body to a safer relation for withdrawal, while securely 
 held, as with hones, vulcanite dentures, pin-buttons, safety-pin>, etc. The points must 
 meet point to point exactly; the bend must be acute and the length of the point from 
 the bend must be short — not over 2 mm. These forceps are especially valuable for 
 the esophagoscopic removal of open safety-pins by the author's metliod nf pushiui! 
 them to the stomach, turning and withdrawing as elsewhere herein ex]>laiued 
 They arc called "rotation forceps." 
 
 Fig. 34. Casscll)erry's forceps for endoscopic pin cutting. When correctly made 
 the ends of the [lin are held by the forceps so as not to be lost. 
 
 Briinings uses an extensible forceps which can be adjusted fur dif- 
 ferent tube lengths. 
 
 Tissue forceps. For the removal of siiecimens fnini any pari of the 
 air or food passages, the author's forceps illustrated in Fig. 3."), far sur- 
 pass anything ever tried by him. The movable jaw will take hold direct- 
 ly on the side wall, and there is no need of a side-acting forceps. Indeed, 
 a side-acting forceps will not work because it cannot be pushed sidewise 
 unless the lateral push is furnished by the movement of tiie endoscopic 
 tube. ^\ ith the forceps illustrated in Fig. o.t, however, a ready hold is 
 gotten in anv kind of tissue withoiu any lateral movement of the endos-
 
 l.NSTRUMKNTS. 
 
 :?7 
 
 copic tube through whicli tlic fiirceps is passed. 'I'he jaws can be turned 
 in any direction, though the author's own personal habit, as with foreign 
 body forceps, is to leave the jaws fixed in the up and down direction and 
 to get all movements by placing the handle, during the work, in tlie de- 
 sired position, leaving the jaws always in the same ])osition rclati\e to 
 the handle. It is wonderful what facility can be de\clij|ied by using this 
 
 -yt^ 
 
 Fig. 3$. Autlior's tissue forccp.';. The side jaw will liite into a flal lateral wall. 
 The cross forms the l)ottom of a haslcet to hold the tissue removed. The action is 
 very delicate, tliere being no springs. The sense of touch can often make the diag- 
 nosis. The best form for removal of a specimen and for endoscopic operations. The 
 actual lengths of the forceps cannulae arc 60 cm. and 30 cm., respectively; the latter 
 being for laryngeal use. 
 
 Fig. 36. Author's alli.ijator punch fnrccps with bar across both upper and low- 
 er rings to form a "basket " to hold the excised fragments. These forceps will go 
 thnjugh the author's adult laryngoscope, but he finds it advantageous to insert the 
 forceps alongside the laryngoscope, wliicli latter is only used to look through in the 
 ocular guidance of the forceps. 
 
 method. ( >f course. diliereiU lengths are re(|uircd fur work in the larynx 
 and in llic esophagus, but clinicall\' forceps wUli a :in cm. cannula 
 are best for llic larynx. an<l a I'H cm. c.imuila will cover all other 
 needs. Tiiere are no springs to opfjose the bite, .uid it is olten ])i)ssiblc 
 to distinguish the nature of the tissue bitten by tlic sensation coiniuum- 
 caled to the fingers, so delicate are the toucb ,nid action of llic forceps. 
 
 Sliding ])unch forceps shonld ha\c the upper ring the smaller one in 
 order that the view of the growth, as the jaws close, shall not be oii-
 
 38 
 
 INSTRUMENTS. 
 
 scured, as would be the case if the nearer ring were the larger. Thus 
 precision may be assured in operating or in the removal of specimen, as 
 the case may be. The author has seen a number of instruments in the 
 shops with his name attached, in which this arrangement of jaws has 
 been neglected (Fig. 37"). 
 
 With a guillotine attached to the author's tissue forceps, a project- 
 ing mass may be amputated without injury to the basal tissue where this 
 is deemed desirable. 
 
 Mouth-gag. Wide gagging, as pointed out by the author (Bib. 3.3G), 
 prevents proper laryngeal exposure and may thus defeat efiforts at bron- 
 
 F'&- 37- Correct and incorrect forms of punch forceps. A, correct model. The 
 near jaw is the smaller. B and C incorrect forms. The near jaw is the larger, and, 
 consequently, obscures the view of the cutting edge. B has a swell on the shank 
 which also obscures the view. 
 
 Fig. 38. Boyce thimble bite block, to be used instead of a gag to prevent the 
 patient biting the tube. A gag makes peroral endoscopy difficult by jamming the 
 mandible down on the hvoid bone. 
 
 choscopy and esophagoscopy by forcing the mandible down on the hyoid 
 bone. All that is needed in the way of a gag is a bite block to prevent the 
 patient closing his jaws on the delicate tube. For this, Dr. Boyce devised 
 the thimble bite block (Fig. 38) which has recently been modified in 
 shape by Dr. McKee and an ether tube has been added by Drs. McKee 
 and McCready (Fig. 39). Ether is insufflated when needed for esoph- 
 agoscopy. In bronchoscopy the insufflation is done through the bron- 
 choscope if general anesthesia is used.
 
 INSTRUMENTS. 39 
 
 Stiarcs. For indirect laryngoscopy the snare has the advantage that 
 it can do no harm as could the forceps if misapplied. For direct laryngo- 
 scopy the forceps can be used so accurately that the snare is rarely use- 
 ful except for large tumors of the larj-ngopharynx and the upi)er laryngeal 
 aperture. For these purposes and for the amputation of the cancerous and 
 the tuberculous epiglottis the author has found useful a \ery heavy snare 
 cannula (Fig. 41) armed with Xo. "> steel piano wire and fitted to the 
 
 Fig- 39- Thimble bite block (on finger) originally suggested by Boyce and im- 
 proved by McKee and McCready. Ether is insufflated through the tube, if needed, 
 for esophagoscopy. The tulie on the bite block is not used in bronchoscopy. 
 
 .r^rrTnTtfTTIimmnil 1^:^^^=! 
 
 Fig. 40. Author's mechanical spoon for the endoscopic removal of soft friable 
 bodies like beans, peas, meat, and nut kernels. The spoon-shaped extremity is in- 
 serted alongside the intruder which is then lifted and drawn into the cud of the 
 bronchoscope or esophagoscnpc- by the action of the s|>oon when the handle is de- 
 pressed as shown by the dotted line. 
 
 massive handles of the Peters tonsil snare. By firm downward pressure 
 on the cannula the loop can be made almost completely to amputate the 
 involved epiglottis cii masse, as demonstrated by dis.section of the re- 
 moved tissues. The cannula is passed beside the laryngeal speculum, not 
 through its lumen. Bronchoscopic and esophagoscopic snares are oc- 
 casionally of service in solving the mechanical problems of foreign body 
 extraction. The authur on r.irc occasions uses a verv delicate snare
 
 40 
 
 INSTRUMENTS. 
 
 (Fig. -18) made to work on a slight modification of his universal handle 
 In use, the snare loop is given a bend or a double curve in one of many 
 ways (a few- of which are shown in Fig. 42) in order that it may be 
 placed by sight. The wire is easier seen among the mucus if it is not 
 bright, black wire giving the strongest contrast. The end of the snare 
 cannula is so made that the loop can be rotated, and also so that the wire 
 cannot be draw n all ibc way in nor kinked : therefore the same wire can 
 be iHished or pulled out and reapplied after an unsuccessful attempt. 
 
 1 looks should have 'i cm. of the proximal end of their stem bent 
 down, cxacth in the opposite direction from that of the hook, to for:n 
 
 Fig. 41. Heavy snare cannula to be attached to the handle of Peter's tonsil 
 .-nare For the en masse removal of the diseased epiglottis or large tumors of the 
 lower pharynx and upper laryngeal aperture. Chondromata and even the toughest 
 of fibromata are readily removed with this snare. The snare is passed alongside 
 the laryngoscope, not through it. 
 
 Fig. 42. Bronchoscopic snare to tit the author's form of forceps handle, llie 
 various shapes, shown in the lower illustration, are imparted to the snare loop as 
 needed to solve the mechanical proljlem presented by the particular case. 
 
 a handle in order that the exact direction of the hooked end may be 
 known to touch as well as sight. The Lister hook and the half-curved 
 and full-curved hooks of Killian have done gOod service. Ingals has de- 
 vised a corkscrew -hook to bring a pin into the center of the lumen. 
 
 Richardson (Bib. 4 b^ ) has devised an ingenious screw-pointed ex- 
 tractor with which he removed a rul)l)er pencil eraser. 
 
 Spectacles. A most important part of the armamentarium is prop- 
 er spectacles specially devised for the work. If the endoscopist has no 
 refractive error he will need two pair of jilane protective spectacles with
 
 INSTKl.-Ml'.Nl'S. 
 
 41 
 
 B 
 
 Fijr. 4,!, Cups for anesthetic solutions designed originally by Vankaucr for 
 nasal use. Being heavy and broad based, they do not upset readily. The author 
 has had a red band painted on one (B) which is for 20 per cent solution, which is 
 used with great caution. 
 
 Fig. 44. The author's endoscopic syringe for injection of solutions of radium 
 salts, local anesthetics, and other medicaments. It is made in 60 cm. length for 
 bronclioscopic and csophagoscopic \\-,e, 30 cm. for direct lar\ngoscopic use. The 
 capacity is 25 mgm., though it could be made for larger quantities of solution if 
 desired. 
 
 Fig. 45. The author's small ililiitor lor lirunchc i^cupic dilatation of bronchial 
 strictures. The dilator is actuated b.\ the author's universal forceps handle. 
 
 F'ig. 46. The autlKrr s l.irgcr dilating forceps with a channel in each member. 
 so as to furnish a canal when the dilator is closed for insertion. In use, this canal 
 permits the dilator to be pushed down over the presenting point of such bodies as 
 tacks. An enlarged form of this is sometimes used for the larynx.
 
 42 
 
 INSTRUMENTS. 
 
 ven' large eyes. If astigmatic, hypermetropic or myopic, correction is 
 necessary and duplicate spectacles must be in charge of a nurse. If 
 presbyopic, two pair of spectacles for 40 cm. distances and two pair for 
 65 cm. distance must be at hand. The reason for duplicates is that there 
 is little or no loss of time in cleaning spattered lenses. One nurse is de- 
 tailed for spectacles and she keeps them on a gauze-covered basin of 
 warm water on the stand of which hangs a dry towel. The nurse cleanses 
 the soiled spectacles and has them ready for immediate exchange. Hook- 
 
 « 
 
 -zr cm. _ . 
 
 \ 
 
 Fig. 47. The author's galvanocautery electrode for endoscopic use. It is es- 
 pecially adapted to cauterization of subglottic edema, and subglottic hyperplasia 
 such as follows diphtheria. As with the author's pointed electrode (Bib. 269) the 
 hard rubber is vulcanized onto the conducting wires, assuring cleanliness. Thread 
 wound electrodes become filthy with blood and secretions. 
 
 ESijta 
 
 Fig. 48. Mosher's esophageal dilator. B. Actual size of distal end. 
 
 =^<S>e 
 
 Fig. 49- 
 vcrtebrated. 
 
 I'luminer's double olive bougie. The stem between the two olives is 
 
 temple frames should be used. Eye-glasses are objectionable because 
 they are not so quickly placed by the nurse when exchanging, and also 
 because they are very apt to become displaced while working. Of course, 
 the operator cannot handle them after he has sterilized his hands. 
 
 Endoscopic table. In an emergency any sort of table can be used, 
 but where a special table is to be provided, the best one to be obtained is
 
 INSTRUMENTS. 
 
 4;? 
 
 that of Dr. T. R. French (Fig. 54) designed especially for nasal and 
 throat operations. The ease with which a trained assistant can raise or 
 lower, or change the angle of inclination of the patient is a great con- 
 venience. The shortening and lengthening of the head-end of the table 
 enables the operator to have any desired degree of overhang of the shoul- 
 ders. All of these movements are under perfect control of the wheels 
 manipulated by the second assistant. The table should be covered with 
 a good pad against which a child can be held firmly without discomfort. 
 Oj^erating room. All peroral endoscopy, except the diagnostic ex- 
 aminations of children suspected of diphtheria, should be done in an 
 
 Fig. 50. Author's eyed bougie for esophagoscopic threading over a swallowed 
 braided silk string. Twelve bougies with successive sizes of olives are made. The 
 pro.ximal end of the string is threaded through the esophagoscope. The esophago- 
 scope is passed ; then the bougie is threaded and passed along the thread which is 
 held taut. 
 
 Fig. 51. Upper illustration. Author's eycd-probe for endoscopic use. Lower 
 illustration. Author's string-cutting esophagotome. The braided silk cord works 
 in a protecting groove on one side of the olive, the cutting being done on the other 
 side which is turned toward the cicatrix when the latter is not annular. 
 
 operating room. A room which can be darkened is a necessity for en- 
 doscopy. Absolute darkness is of course not necessary nor desirable. 
 There should be enough illumination, of a feeble kind, to permit the 
 nurses and assistants to find wdiat is needed on the sterile table. It is 
 quite necessary that whatever windows there are should be at the back 
 of the operator, because a little streak of light leaking in past blinds and 
 shining directly into the eye of the operator, is partictilarlv annoying and 
 an inconvenience. The expert operator will get along with quite a bright
 
 a IXS'I'KUMI'.XTS. 
 
 light in the ronni. but when it comes to intricate and difficult work, it is 
 necessary to have a darkened room. All endoscopy should be done with 
 both of the endoscopist's eyes o]jen. Prolonged work with the left evelid 
 closed is very fatiguing, and interferes with \ision of the right. Ignoring 
 of the image of the open left eye is facilitated by a darkened room. 
 
 Operating room orqanicatioi. Once an endoscopic procedure has 
 been starteil, moments are exceedingly precious. For this reason, every de- 
 
 CLOSED 
 
 OPEN 
 
 Fig. $2. .\uthor's dilator for endoscopic use in lironchial and esophageal stric- 
 tures. Invaluable in dilating successively each of a series of strictures, especially 
 when the lumina of the lower ones are eccentric to those above, because it does 
 not need to be inserted far. 
 
 ,c 60-cm- 
 
 B 
 < -lo-cm^ > 
 
 Fig. 53. Filiform bougie for minute cicatricial strictures of the esophagus. 
 The filiform silk woven end, A, is joined securely to a spring steel shaft, B, thus 
 giving all the advantages in safety of a silk woven bougie at the tip with a stiflf 
 shank that enables the bougie to be carried down rigidly through the length of the 
 esophagoscope. Twelve sizes are made. The total length of 60 cm, is only neces- 
 sary in case of a very low stricture in an adult. For use in children, the bougie 
 ran be shortened by unscrewing. The great advantage of the steel shaft over any 
 sort 01 stylet inserted into a hollow filiform is that the small diameter of the steel 
 shank permits of more accurate ocular guidance. These bougies are modeled after 
 those of Guisez. 
 
 tail must be carried out including c\ery instrument that would e\er be 
 wanted. Instruments not likely to be needed are kept sterile on a se[)arate 
 table, so that the working table will not be encumbered by anything but 
 the regular working-set of instruments. The tubes are all kept with tin; 
 batteries in the manner shown in Fig. 5."), so that the surplus tubes not 
 in use will in no way interfere with the quick handling of forceps and 
 sjionge carriers. The arrangement of the instrument table, the assistants, 
 the batterv, instrument nurse and anesthetist, as shown on page 4i) in
 
 IXSTRUMKNTS. 
 
 45 
 
 the earlier volume, lias lieeii [)roven to be invaluable in expetliting care- 
 ful work. The great advantage of having these regular positions is the 
 avoidance of confusion. Anything needed is always in precisely the 
 .■^ame location. The author has been able by this means to do just as 
 good work in one hospital as in another by taking an assistant and a 
 nurse with him. This, however, is not meant to say how good or how 
 bad the work may have been, but such as it was, it represented the liest 
 that the author could do under any circumstances. 
 
 O.vyc/ni tank and tracheotomy instruments. In all instances, as a 
 matter of routine, instruments for traclieotomy should be on the sterile 
 table read\- for immediate use in every case of bronchoscopy or esoph- 
 agosco[)y. or direct l;>ryni,mscopy. It is exceedingly rarely, rclatixcly, 
 
 Fig. 54. Dr. T. K. Frenfli operating talilc. All positions are readily obtained 
 by tbc three control wheels. The bead board can be extended or shortened to bring 
 the shonlders of the patient to the best position. 
 
 that they will lie reipiired, but when nee(le<l, ihey should be immediately 
 at hand, sterile and ready. Ily having these preparations always part of 
 the sterile table sellings, a few lives can be saved that ollierwise would 
 be lost by the delay or by sepsis. An ox\gen lank in a roller stand 
 (Fig. .")(>) is most manageable. It shotild be covered with sterile towels 
 pinned on, over valve-wheel and all, and a length of sterilized rubber tub- 
 ing should be connected. I f this lank should be prepared only in such 
 cases as may seem beforehand likely to need it, the surgeon will find, to 
 his chagrin, that when most wanted it will not be at hand. It is just 
 such little details that make the dift'erence between high ami Idw morlal- 
 itv in anv siu'gical procedtire. In rcspir.itory arrest from the pressure 
 of the esoi)hagoseope or of the foreign body, lumor, diverliculnm full of 
 food, resi)iralii)n will not be started again unless a bronchosct)pe be in-
 
 4G INSTRUMENTS. 
 
 troduced into the tracliea or a tracheotomy be done for oxygen and amyl 
 nitrite insufflation. Amyl nitrite should always be at hand in the torm 
 of capsules. 
 
 Head cozier. The author uses a head cover for the patient, which 
 is simply a muslin bag large enough to go down to the shoulders. A 
 round hole about four inches in diameter is cut at the level of the mouth. 
 This cap enables the operator and the second assistant to hold the head 
 without infecting their hands. It involves a grave risk to handle instru- 
 ments that go into the lung after handling a patient's head. 
 
 Asepsis. The author's early insistence (Bib. 2(39) upon strictly 
 aseptic operating-room technic in all forms of peroral endoscopy, w'hile 
 much ridiculed at the time, has come to be recognized everywhere as quite 
 essential in a procedure which necessarily fre(|uently comes in contact 
 with tuberculosis, pneumonia, diphtheria, erysipelas, lues and other in- 
 fectious diseases and pyogenic infections. It is a matter of great grat- 
 ification to the author that in fifty examinations of swabs used for wiping 
 secretions from the bronchi, in no instance was there found any trace 
 of such epithelial cells or of such forms of bacteria as would prove that 
 the instruments had been in any way contaminated by contact with the 
 mouth. This is worthy of note in connection with the obtaining of 
 inoculation material for the production of autogenous vaccines in cases 
 of chronic bronchitis, etc. 
 
 As before pointed out (Bib. 2(i9), it is necessary to remember that 
 though the field cannot be sterilized, yet the patient is more or less im- 
 mune to the organisms that he, himself, harbors, while he may be ex- 
 tremely susceptible to organisms introduced from another source, even 
 though such newly-introduced organisms mav be morphologically the 
 same. Bacteria from the patient's own skin and hair come under the 
 class of foreign organisms wdien introduced into the lungs or into the 
 blood and lymph channels in operative work. The only way to be cer- 
 tain of avoiding the introduction of ])athogenic organisms from a previ- 
 ous patient, or from any other source, is to carry out all the details of 
 aseptic operative technic. Then if a patient gets pnemnonia or any other 
 infection the operator has all the comfort of a clear conscience. A mask 
 should always be worn by the operator to protect both the patient and 
 himself from infections that either may unknowingly have. It is not 
 pleasant to have even uninfective secretions coughed in one's face. Large 
 plane protective spectacles should be worn over the o])erator's eyes it 
 he does not rccjnire corrective lenses. The patient should be covered 
 with a sterile gown, and a cap coming down to the shoulders with a 
 hole in it corresponding in position to the mouth, but larger: about ID 
 cm. in diameter. Assistants, even the one who holds the head, and also
 
 INSTRUMKNTS. 4? 
 
 the anesthetist, if one is needed, should put their hands through the same 
 process of sterihzation as for any surgical operation. All of the sterile 
 team should wear sterile caps. Instruments should be sterilized by boil- 
 ing, except the lamps, light carriers, knives and scissors. These should 
 be immersed in alcohol. Extra lamps should be sterilized so as to be 
 ready if needed. Conducting cords may he wiped with alcohol, but it 
 must be strong alcohol, because alcohol diluted with water may tem- 
 porarily impair insulation. Conducting cords should be covered with 
 close-fitting rubber tubing for cleanliness. 
 
 LIST OF INSTRU.MliXTS. 
 
 The following list, given as a convenient basis for equipment, has 
 been listed from the author's armamentarium. The essentials for ordi- 
 nary work are marked with an asterisk. Bougies, dilators and the like 
 are not so marked because they are not emergency instruments ; though 
 they are essential to the endoscopist who expects to deal with all kinds of 
 cases. Special instruments may need to be devised for special 
 cases. The instruments listed, unless names are mentioned, are of the 
 author's design. These might not suit others, and it is better for the en- 
 doscopist personally to examine and select instruments that appeal to 
 him personally. 
 Tubes: 
 
 *1 direct laryngoscope for children. 
 
 *1 direct laryngoscope for adults. 
 
 *1 bronchoscope, I mm. x '.W cm., for children. 
 
 *1 bronchoscope, 'i mm. x ;50 cm., for children. 
 
 *1 bronchoscope. 7 mm. x 10 cm., for adults and older children. 
 
 *1 bronchoscope, !• mm. x 40 cm., for adults. 
 1 esophageal speculimi for cliildren. 
 1 esophageal speculum for adults. 
 
 *] esophagoscope, 7 mm. .x -J-") cin., fur ibildren. ( Slanted end. ) 
 1 esophagosco])e, fi mm. x \'> cm., for older children. 
 
 *1 esophagoscope, 10 mm. x 'i'-i cm., for adults. (Slanted end.) 
 Extra lamps. (At least 1 dozen.) 
 Accessories : 
 
 *1 bite block. McCready-McKee. 
 
 *l Sajous laryngeal cotton forceps, long, full, curved. 
 
 *1 as])irator and tubing for both i)ositivc and negative pressure. 
 
 *ls sponge holders with long screw collar. 
 
 *1 force])S, plain foreign body jaws with handle I") cm. and (>0 cm. 
 1 forceps, side curved, with handle 4.') cm. and (>0 cm.
 
 48 INSTIU'.MlCKTS. 
 
 I t'orce])s, with r()tati<in jaws with liandle, 1-") cm. and (io cm. 
 
 1 Ca.sselheiiy'.s pin-cutting forceps. 
 *1 laryngeal tissue forceps with basket tip. 
 *1 Moshcr alligator forceps. 
 
 1 jninch forceps with roimd and triangular jaws. 
 
 1 guillotine forceps. 
 *1 mechanical spoon. 
 
 1 bronchoscopic snare. 
 
 1 esophagoscopic snare. 
 
 1 Lister hook. 
 *1 full-cur\ed hook. 
 
 1 half-curved hook. 
 
 2 bronchoscopic dilators, large and small. 
 
 1 safety-pin closer. 
 
 *1 steel measuring rule, 2(1 cm. long. 
 
 2 cautery electrodes and cord. 
 1 Ijcnt hook mouth-aspirator. 
 
 ] laryngeal dilator, parallel blades. 
 
 1 Mosher's esophageal dilator for cardia. 
 Bougies metal with silk-woven ends, 
 liougies, double olive. 
 
 I'orcelain cups for local anesthesia scilutions, 1 with reel ban<l. 
 *Sponges, a .good suppK- would be abnut 1 dozen of each size. 
 
 ■i extra battery cords. 
 *2 dry cell batteries with two circuits each. 
 
 2 battery covers. 
 
 1 face cap for patient. 
 
 Tracheotomy instruinents. 
 
 Extra spectacles with large lenses to protect ojierator's eyes. 
 Care of instnniioils. Next in importance to ha\ing a well-made 
 and carefully selected instrumental eijuipment, is the keei)ing of the 
 equipment in proper order. iMir this pur[)ose the endoscojVist should have 
 an instrument nurse in his own employ, or he should look after the care 
 himself, for, imfortunately, the constantl\- changing working-force in the 
 usual operating room results in the instruments falling into the hands of 
 a new nurse at freeinent intervals, and alas too often a pupil-nin\se, who, 
 however competent to scrub and [lolish the instruments of the general 
 surgeon, will work sad havoc with the endoscopist's equipment; and con- 
 sequentU- the next time a bronchoscopy is in order the endoscopist will 
 find his work dilticult or impossible because of forceps bent or corroded, 
 small parts lost, tubes dinged, canals choked with blood or secretions, 
 adherent to the inner walls and coagulated by boiling. The sooner the
 
 INSTRUMENTS. 
 
 49 
 
 endoscopist realizes that he is simply a mechanic ami that to do good 
 work a mechanic must have good tools kept in proper order, the better 
 his results will be. Otherwise, he will never obtain the high percentage 
 of successes of the good mechanic who keeps his tools in good order. 
 To keep instruments in the proper condition recpiires not oidy good care 
 but very frc(|uent careful inspection, for the fre(|uent cleansings. tiie tak- 
 ing apart and putting together, the boiling as well as the actual use of 
 the instruments, result in deterioration. Tiiis applies especially to for- 
 ceps, which ha\e the heaviest work to do, and which must necessarily be 
 delicate in construction. The jaws at the end of all forms of tube for- 
 
 Fig. 55. Manner of arranging sterile instruments and batteries. Tlie battery 
 lids are opened back outward in opposite directions, tben each is covered witb a 
 special sterile cover. The crevice Ijetween is used to bold tubes wbich are readily 
 identitied liy tlieir distal ends which are always uppermost. Laryngoscopes are in 
 the battery lids. 
 
 ceps arc necessarily tcnii)ered to a s[)ring temper. If the temper is a lit- 
 tle too high, nr if slight corrosion has taken jilace. the forceps are very 
 apt to break. 'J'his is an exceedingly embarrassing accident resulting not 
 only in the loss of the foreign body, but in the introduction of a fresh 
 foreign body in the form of a lost part of the instrument. Consequently 
 after much use it is wise to throw away the stylet jaws of tube forceps 
 and replace them with new ones. This, with careful inspection before 
 each operation, will ])revent accidents and failures. After operation tlie 
 canal for the light carrier, and in the case of the esophagoscoiie. the drain- 
 age canal, should be cleaned first, by forcing cold water through the canal 
 with the aspirating syringe, and then by pushing through a long cotton
 
 50 
 
 TNSTRUMKNTS. 
 
 brush formed on wire, such as used for cleaning the canal in the stem of 
 a tobacco pipe. As usually sold in the tobacco shops it is cut in short 
 lengths, but it can be obtained from the factory in coils. It is stiflf enough 
 to be pushed through the canals, provided the canals are always cleaned 
 immediately after operation and the secretions not permitted to stick in 
 the canal, either by coagulation or by boiling. Forceps should be taken 
 apart and the cannula cleaned thoroughly by running cold water through 
 it. The stilette should be cleaned and then polished with a bit of emerj- 
 paper and carefully oiled before replacing it in the cannula. If the can- 
 nulae of forceps are made of spring-tempered brass tubing, they are 
 
 Fig. 56. Ox)'gen tank- stand. Very light and convenient to go under the head 
 of the operating table when needed so as to be out of the way during bronchoscopic 
 oxygen insufflation. 
 
 much less subject to corrosion than steel is to rust. It is necessary to see 
 that the sliding edges of the direct laryngoscope are not injured and that 
 the slide works freely and comes away readily, unless as is now done by 
 many the oval laryngoscope is used without the slide. Roughness of 
 tubes is readily detected by passing the finger all over them. The distal 
 ends are particularly prone to get little rough places. Rubbing with the 
 smoothest quality of emery paper will remove roughness. Some of the 
 plating may be thus removed, but the author prefers instruments not plat- 
 ed anyway, for jjlating is apt to scale off. To keep in order batteries of 
 the form used by the author, it is only necessary to renew the dry cells
 
 INSTRUMENTS. 31 
 
 once every three or four months, whether used or not. If care is taken 
 to see that all connections are screwed up tightly, no one should ever fail 
 for want of current. Before sterilizing, the cords and lamps should be 
 tested, the lamps being allowed to remain in the light carriers which 
 are then immersed in alcohol. 
 
 In over three thousand endoscopies neither Dr. Patterson nor the 
 author has ever failed for want of a light. This has not been a matter 
 of luck ; but rather a little attention to see that everything is right before 
 starting, and the observance of a rule always to have a duplicate in re- 
 serve, precisely as is done in all commercial lighting installations or in 
 the "dual ignition" systems of modern internal combustion motors. This 
 is not boasting. It is too trivial a matter. In fact the matter is so very 
 trivial that few operators will give the electric details any attention. 
 There is no mystery about electric trouble ; and he who is master of his 
 instrument and its few and simple details will always have satisfactory 
 light. \'iolin strings are prone to break; but this does not cancel the vir- 
 tuoso's concert nor make him resort to wire strings.
 
 CHAPTER II. 
 
 Anatomy. 
 
 Anatomical knowledge of the kind rec|uired for bronchoscopy and 
 esophagoscopy cannot be obtained from a book. The anatomy of the 
 tracheo-bronchial tree and of the esophagus was considered in the au- 
 thor's earlier work. In addition to the notes there given the broncho- 
 esophagoscopist is advised to study the anatomy as given in the standard 
 anatomical works and then to pass the bronchoscope and the esophago- 
 scope repeatedly on the cadaver with the thorax opened to full view in 
 order to get in mind the precise relations of the various surrounding 
 viscera. As the identification of landmarks is very much easier on the 
 cadaver because of the stillness and the absence of renewal of secretions 
 once they are removed, the bronchoscopist should practice the identifica- 
 tion of the bifurcation and of the orifices of the upper, middle and the 
 lower lobe bronchi on the right side, and of the upper and lower lobe 
 bronchi on the left side. \'ariations of the endoscopic appearances in the 
 tracheo-bronchial tree and in the esophagus were considered in the earlier 
 work and will be alluded to still further when writing of the introduc- 
 tion of the bronchoscope and of the esophagoscope. The articles of In- 
 gals. ]jrown-l\elly, Mosher, and particularly the interesting article of 
 LieliauU ( Bib. :y29 ) and the verv elaliorate paper by iMchnert (Bib. 404 I 
 are well worthy of careful study. The latter authority distinguishes thir- 
 teen physiological constrictions in the esophagus. For endoscopic pur- 
 poses only four of these need be considered, namely, the cricoidal, the 
 aortal, the bronchial, and the hiatal. To these some authors would add 
 the cardia. Consideration of the endoscopic appearances of the four con- 
 strictions mentioned will be alluded to in connection with the introduction 
 of the esophagoscope. The endoscopic anatomy of the larynx will be 
 studied from the new direct view-point under the heading of direct laryn- 
 goscopy and elsewhere. 'J'he illustrations and even the lan,-ngeal image of 
 the indirect method are C|uite misleading, and we cannot obtain true di- 
 rect image simjily by inverting a drawing of the indirect image.
 
 CHAPTER III. 
 
 Preparation of the Patient for Peroral Endoscopy. 
 
 The suggestions of the author in the earHer \-olunie in regard t(j pre- 
 paration of the patient, as for any operation l)v a Lath, laxative, etc., and 
 especially by special cleansing of the mouth with 'i'> per cent alcohol 
 have received general endorsement, .\rliticial dentures should be re- 
 moved. Even if no anesthetic is to be used, the patient should he fasted 
 for five hours if possible, even for direct laryngoscop)' in order to fore- 
 stall vomiting. Except in emergency cases every patient should be gone 
 over by an internist for organic disease in any form. I f an endolaryn- 
 geal operation is needed by a nej^hritic, preparatory treatment may pre- 
 vent laryngeal edema or (jther complications. Hemophilia should be 
 thought of. It is (|uite common for the first symptom of an aortic 
 aneurysm to be an imjiaired ]w\ver to swallow or the lodgment of a 
 bolus of meat or other foreign body. If aneurysm is present and esoph- 
 agoscopy is necessary, as it always is in foreign body cases, "to be 
 forewarned is to be forearmed." I'ulmonary tuberculosis is often un- 
 suspected in very young children. 'I'liere is great danger from tracheal 
 pressure by an esophageal dixerticiiluni or dilatation distended with 
 food : or the food may be regurgitated and aspirated into the larynx 
 and trachea. Therefore, in all eso])liageal cases the eso])hagus shottld 
 be eniptieil by regurgitation induced bv titillating the fauces with the 
 finger alter swalkiwing a tumblerful of water, pressure on the neck, etc. 
 .Aspiration will succeed in some cases. In others it is absolutely neces- 
 sary to remo\e the fnod with the esophagoscope. If the aspirating tube 
 becomes clogged b}' solid food, the method of swab aspiration mentioned 
 under bronchoscopy will succeed. ( )f course there is usualU' no cough 
 to aid, but the iii\iphiiit;u"\ ;iliilominal and thoracic compression helps. 
 Should a patient arrive in a serious state of water-hunger, as explained 
 under "t'onlraindicalions to Esoijhagoscojjy," the patient must be given 
 w.'iter by hy])(j(lermoclysis and enteroclysis, as ]iart of the preparation 
 and if necessary the endoscopy, except in dyspneic cases, must be de- 
 layed until the danger of water-starvation is jiast. 
 
 Every patient should be exannned by indirect, nnrior laryngo>cop\ 
 as a prelimin;iry to peroral endoscojjy for any jjurpose whatsoever ; and 
 it becomes doubly necessary in cases that are to be anesthetized as ex- 
 l)lained in the beginning of the chapter on direct laryngoscopy.
 
 CHAPTER IV. 
 
 Anesthesia for Peroral Endoscopy. 
 
 While it is impossible to lay down any hard and fast rules for anes- 
 thesia in tube work, yet the time has arrived when we may formulate 
 a few general principles from which deviation can be made to suit the 
 particular case or the operator's personal equation. The herein given 
 rules were submitted by the author for discussion at a meeting of the 
 American Laryngological Association.* 
 
 In the very interesting and extensive discussion which followed, 
 the conclusions were endorsed in the main. Particular emphasis was 
 placed upon the statement that the personal equation of the operator and 
 of the particular case should govern the question as to whether general, 
 local, or no anesthetic at all is to be used. 
 
 Total abolition of the cough-reflex should only be for short periods. 
 The facile operator will do good work in many cases in spite of a mod- 
 erate degree of cough. After a short period of tubal contact in bronchos- 
 copy, coughing lessens and often practically ceases, especially in infants. 
 Following the general rule in surgery, an anesthetic should never be used 
 at all unless necessary ; never in greater quantity than the needed mini- 
 mum. In general surgery, anesthesia is required for three purposes : 
 (1) The obtunding of pain (reallv analgesia) ; (3) the abolition of re- 
 flexes (relaxation), and (3) for psychic efTect (mainly abolition of ap- 
 prehension). For peroral endoscopy, analgesia is not required, for the 
 pain in careful work is exceedingly slight ; but anesthesia for the lessen- 
 ing of the reflexes and for the lessening of the apprehension which in- 
 tensifies the reflexes, is necessary under certain circumstances. These 
 reflexes are manifested by spasmodic action of certain muscular systems, 
 chiefly those of vomiturition and coughing. In so far as these may be 
 excited by mucosal contact they may be controlled by local anesthesia 
 alone ; for, of course, local anesthesia is purely and simply mucosal anes- 
 
 •Proceedingrs Amer. Laryng:ol. .\ssociation. Ill 12. p. gs.
 
 ANESTHESIA I"()!< PERORAL ENDOSCOPY. 55 
 
 thesia. Muscular contractions, as well as pain, resulting from psychic 
 mechanism, or traction upon tissues remote from the mucosa can only 
 be controlled by deep general anesthesia, or to a less degree, by the con- 
 trol of the patient's mental state by the personality of the operator. The 
 degree of this control varies widely with the personal equation of the 
 operator as well as of the patient. The operator who can keep his pa- 
 tient free from apprehension and who can keep his patient's mind fixed 
 on the task of breathing slowly, deeply, and regularly will get along 
 without any anesthetic and do better work than another operator under 
 profound general anesthesia. As Briinings has pointed out, the operator 
 who is not sufficiently practiced to pass the tubes without general anes- 
 thesia is not justified in using general anesthesia to overcome faults in 
 technic. 
 
 .Incstlit'sia for esophagoscopy. 1. For foreign bodies, no anes- 
 thetic is needed in either adults or children, except in case of very large 
 and shaqj foreign bodies, wherein the relaxation of the esophageal mus- 
 culature, by deep general anesthesia, will obviate the trauma incident to 
 the withdrawal of the intruder through a spasmodically constricted 
 lumen. 
 
 2. In case of a sharp foreign liody threatening perforation, espe- 
 cially open safety-pins, it is safer to abolish antiperistalsis by deep gen- 
 eral anesthesia. 
 
 .'!. In cases of suspected esophagismus and "cardiospasm," the spas- 
 modic element can be entirely eliminated by deep general anesthesia. 
 
 4. In case of large foreign bodies, general anesthesia adds enor- 
 mously to the danger of respiratory arrest from pressure of the foreign 
 body on the trachea and on the peripheral nervous respiratory mechanism. 
 
 5. The use of a general anesthetic will greatly lessen the need for 
 skill in the introduction of the esophagoscope ; but such use is utterly un- 
 justifiable. 
 
 (i. Local anesthesia is needless for esophagoscopy. If used at all, 
 it should be applied only to the laryngo-pharynx, never to the esophagus. 
 
 .hnstliesia for direct laryngoscopy. 1. For diagnosis. In infants 
 and children, no anesthetic whatever in any case. In adults who tolerate 
 indirect laryngoscopy well, no anesthetic, general or local, is needed. 
 
 2. Foreign bodies. In infants and children, no anesthesia, general 
 or local. 
 
 .'i. P'or the removal of foreign bodies fnjm the larynx, both local 
 and general anesthesia should be avoided, lest their application lead to 
 dislodgment of the intruder. 
 
 4. For papillomata in children, no anesthetic, general or local, is 
 needed. In adults, local anesthesia is usually necessary for accurate 
 work in removing specimens or entire neo[)lasnis of any kind.
 
 56 ANESTHESIA FOR PEKORAL ENDOSCUl'V. 
 
 •J. In a few adults, intolerant and uncontrollable general excitability, 
 and in some cases of hysteria a general anesthetic may be necessary for 
 accurate work in the removal of laryngeal neoplasms ; but such cases are 
 exceedingly rare. 
 
 Oral bronchoscopy. 1. For diagnosis, in children, no anesthesia, 
 general or local : in adults, local anesthesia of the trachea and bronchi, as 
 well as of the larynx will be needed. 
 
 2. For foreign bodies in the trachea anil bronchi of infants and 
 small children no anesthetic, general or local, is needed, except possibly 
 in very complicated removals, such as in case of open safety-pins. For- 
 eign bodies in the trachea and bronchi of adults can often be removed 
 without any anesthesia, general or local ; but in most cases local anes- 
 thesia is needed. General anesthesia is needed only in complicated cases 
 where there is a stricture to dilate to reach the foreign body, or w'here 
 the mechanical problem of removal is complex, or where the cough 
 threatens to cause perforation. 
 
 :'. For the after-treatment of stricture local anesthesia is sufficient, 
 and in some cases none is needed, because tolerance to manipulation be- 
 comes established after repeated passage of the instruments. 
 
 Trachcotomic bronchoscopy. If lower bronchoscopy is ever justi- 
 fiable, it is only so in cases with extremely severe dys])nea, and even in 
 such cases the facile operator will slip in a bronchoscope, through which, 
 with the aid of amyl nitrite and oxygen, artificial respiratory aid can be 
 supplied with greater facility than through a tracheotomy wound. Should 
 the bronchoscopist prefer tracheotomv it never need be done under gen- 
 eral anesthesia : and in a dyspneic case general anesthesia is utterly un- 
 justfiable because as soon as anesthesia begins, respiration ceases, owing 
 to the loss of the aid of the accessory respiratory musculature. Cocaniza- 
 tion of the trachea and bronchi may be used for trachcotomic bronchos- 
 copy in adults ; no general anesthetic is necessary. 
 
 General rules for local anesthesia. Anesthetic adjuncts, such as 
 adrenalin, antipyrin. and \arious S3nthetic compounds, the author has 
 never used; consequently, he cannot formulate any rules, even in a sug- 
 gestive way, and he is compelled to rely upon Drs. Ingals. Coolidge, May- 
 er, Alosher. W'inslow. Vankauer, Casselberry. and other eminent co- 
 workers to supply the deficiency. Doubtless, adrenalin by the ischemia 
 which it induces, increases anesthesia and also prolongs it bv slowing 
 the carrying-away of the cocaine by the blood. I'.roniides in large 
 doses, some hours beforehand, as suggested to the author by Dr. Frank 
 D. Sanger, of Baltimore, have a marked effect in lessening cough re- 
 Ilex and lessening the amount of cocaine needed. Morphine has this also, 
 but its use is objectionable because of after-nausea: and in cases where
 
 ANESTIirSIA l-OR 1'|;KI)K.\I. K.NU0SC0I'\'. 01 
 
 repeated sittings arc necessary, there is risk of drug habit, lieruin is an 
 adjunct useful in some cases. Xone of these antibechics should be used 
 in such large doses as to abolish the cough-reflex for a long time be- 
 cause, as the author has frequently pointed out. the cough-reflex is the 
 watchdog of the lungs, (|uicl<l\- ridtling the lungs of irritati\e and infective 
 materials 
 
 For esophagosco])y, local anesthesia is needless. If used at all. its 
 application should be limited to the epiglottis and laryngo-pharj^nx (not 
 hvjjo-pharvnx ). The esophagus is insensitive as anyone may determine 
 for himself by swallowing very hot coti'ee. After the pharynx is passed 
 the burning sensation ceases, though sometimes it is felt again slightly 
 when the stomach is rcachcil. 
 
 KL'LI'.S I'OU TIIK rsi': OF C'OCAI i\"K. 
 
 (1) Cocaine should never be used in infants or small children. 
 
 (2) Its use should be a\oided, if possible, in all cases, such as 
 cases of papillomata. in which frec|uent sittings are necessary. 
 
 f3) The patient should never know the name of the drug. 
 (4) The amount used should be the minimum as to 
 
 (a) Strength of solution. 
 
 (b) Uuantity of solution. 
 
 (c) Mucosal area touched. 
 
 Hence, only certain highly sensitive areas should be touched with 
 the stronger solutions; the less sensitive areas receiving only the weaker 
 solutions, either by direct apjjlication or bv the incidental flow over the 
 moist mucosal surface following the application of the stronger solutions 
 to the highly sensitive areas. 
 
 (■")) Solutions may be ap])lied by 
 ( a ) Spray. 
 ( b I Syrin.ge. 
 (cl Painting -;_\ringe (l!nuiings|. 
 
 (d) Applicator carrying cotton or gauze saturated, but not 
 dripping, with solution. 
 
 Preference should be gi\en to either or both of the ki'^t two methods 
 as being more jirecise. The spray is useful, if the operator desires to use 
 any anesthetic at all in cases of foreign body in the larynx, as a spray is 
 much less liable to dis])lace the intruder than a swab; but for this very 
 reason any form of anesthesia had better be <imitted in cases of laryn- 
 geally lodged foreign bodies. 
 
 ((')) The stomach should always be empty, not only because the 
 tendency to vomiturition and vomiting are thus lessened; but because, as 
 proven bv llrimings, absorjilion of cocaine i-^ thus lessened.
 
 ^ 
 
 Oe ANUSTHESIA FOR PHUORAL ENDOSCOPV. 
 
 The author's technic for local aui-sthcsia. The author has two por- 
 celain jars, thick and heavy, though small, (about 3 c. c.) carried with 
 the instrumentarium. In one, an 8 per cent cocaine solution is freshly 
 prepared, and in the other a 20 per cent solution. The latter is known 
 by a red band around the jar, burned into the porcelain. Fig. 43. This 
 solution is used only with extreme caution and in small quantity. In no 
 case are the jars refilled, hence the total quantity is always limited: and, 
 of course, most of it is thrown away in the swabs and escapes with the 
 secretions, so that only a very small portion of the solutions is absorbed 
 by the patient. Used in this way, the author has never had a serious 
 symptom. This method was adopted after the death of a child in rhyth- 
 mic, symmetrical convulsions one hour after the removal of a papilloma 
 of the larynx under cocaine anesthesia. He has never, however, used 
 cocaine in children since, and never will. All of his endoscopy on chil- 
 dren under seven years of age is done without any anesthetic, general or 
 local, except in a very few cases of complicated foreign-body extractions, 
 such as the closure of safety-pins. The author's method of application 
 for local anesthesia is as follows : With a dossil of cotton held in a 
 Sajous larj'ngeal forceps, the larj'ngo-pharynx is swabbed with an 8 per 
 cent solution of cocaine, by sense of touch, without a mirror After two 
 minutes' wait, the laryngoscope is introduced, and the anterior and pos- 
 terior surfaces of the epiglottis are painted with a small gauze sponge 
 (Fig. 27) saturated with the 20 per cent cocaine solution and carried in 
 with a sponge holder (Fig. 2.")). A fresh sponge is saturated and car- 
 ried through the glottis and down the trachea. After a two minutes' 
 wait, the bronchoscope is introduced if desired and deeper applications 
 made as necessary. The posterior tracheal wall and the neighborhood of 
 the bifurcation are the sources of much reflex-cough, and the bronchus 
 to be entered may need an application ; but the skillful operator will 
 often dispense with local anesthesia after the first application, as the 
 cough-reflex in many instances soon ceases to be troublesome, and a 
 certain amount of cough need not interfere with work. In case of im- 
 pacted foreign bodies, it is of advantage to hold the swab in contact with 
 the surrounding tissues for about half a minute. 
 
 Technic of general anesthesia. For esophagoscopy and gastroscopy. 
 ether or chloroform may be started by the usual method and continued 
 by dropping upon a folded bit of gauze, several layers thick, laid over 
 the mouth after the tube is introduced. Undoubtedly, there is a remote 
 risk from the inflammability of ether, which is too often forgotten. 
 
 For tracheo-bronchoscopy. ether or chloroform may be started in the 
 usual way and continued by holding a gauze sponge with a hemostat in 
 front of the tube, though this means frequent interruption of the work
 
 ANESTHKSIA FOK ri-UOKAL ENDOSCOPV. 59 
 
 as well as of the anesthetic. So far as interrui)tions of the anesthetic are 
 concerned, they are, in the author's opinion, factors of safety, if care be 
 taken to avoid excessively deepening the anesthesia to prolong the inter- 
 val. Or, after starting in the usual way, chloroform and ether may be 
 continued by means of the Buchanan attachment (Fig. 17) directly to 
 the bronchoscopic tube, care being taken carefully to time the insuffla- 
 tions properly in relation to inspiration. It is preferable to start with 
 ether and continue with chloroform, which is relatively (juite safe after 
 the stimulant effects of ether are established. 
 
 ADDITIONAL NOTES ON GENERAL ANESTHESIA FOR PERORAL ENDOSCOPY. 
 
 The foregoing is reprinted here exactly as presented and discussed 
 at the meeting mentioned. The following observations may be added 
 and some points may be emphasized. 
 
 A serious error has crept into medical literature in regard to an- 
 esthesia for direct laryngoscop\-, and unfortunately, error in medical lit- 
 erature persists and is handed down from author to author long after 
 men doing the work realize the error. The statement has been repeatedly 
 made that general anesthesia is necessary for direct laryngoscopy in 
 children, .\othing could be farther from the truth, because in children, 
 no anesthetic, general or local, is required in anv case for direct laryn- 
 goscopy. In certain adults with short, thick necks and of a very muscu- 
 lar tyi)e, with engorged irritable throats it requires a high degree of skill 
 to do accurate work by direct laryngoscopy, even with local anesthesia. 
 In such cases there is ami)le justification for the beginner to use a general 
 anesthetic, provided there is no dyspnea and no obstruction in the larynx. 
 l!ut in children, no one is worthv of the name of direct laryngoscopist if 
 he cannot examine the larynx of any child without any anesthetic, gen- 
 eral or local. Children with papillomata are c|uite likely to die on the 
 table if a general anesthetic be given, unless the operator is exceedingly 
 prompt with a bronchoscopic oxygen insufflation, or a jiromju tr.icheot- 
 omy with insufTlation of amyl nitrite and oxygen. 
 
 In the case of a combative child who is also dyspneic it must be 
 remembered that compelling the child to undergo the anesthetic will be 
 even more than usually dangerous, for dyspnea is always increased by 
 exertion. If a struggle on the part of the patient ends in succumbing to 
 the anesthetic the danger is so great that only cjuick work will save the 
 child. If on the other hand the struggle had ended with the insertion of 
 a bronchoscope instead of the administration of an anesthetic, the child 
 would be safe at the end of the struggle instead of moribund. 
 
 The author has never seen a case of arrested respiration by pres- 
 sure on, or irritation of, the ])crii)heral nervous respiratory mechanism.
 
 (>0 ANESTHESIA 1-OK PEKORAI. EiNDOSCUPY. 
 
 such as the so-called "vagus reflex." Such arrest is, in liis opinion, al- 
 ways due to occlusion of the air passages, for the following reasons. 
 Respiratory arrest never occurs in work without anesthesia unless the 
 air passages are occluded initil the jjatient asphyxiates. On the other 
 hand, when apnea vera has occurred in the cases that have come to the 
 writer's knowledge, it has always been under deep anesthesia, when, of 
 all times, the patient should be less susceptible to reflex arrest of res- 
 piration by presence of the endoscopic tube. Therefore, the author be- 
 lieves that the occasionally given "vagus reflex'' as a cause of death in 
 esophagoscopy or "laryngeal reflex" in bronchoscopy, are unwarranted 
 by the facts. 
 
 Angiomata, edematous polyps, and a few vascular growths will shrink 
 so completely under cocaine as to render accurate removal impossible. 
 When this is found to be the case a general anesthetic will be necessary. 
 
 Small growths projecting from the ventricle in adults may be very 
 readily hidden by the over-riding projection of the ventricular band. 
 This projection is very much more pronounced under even thorough 
 anesthetization by local means, so that unless extremely expert, the 
 operator will require the use of general anesthesia, which has the eft'ecl of 
 lessening very much the projection of the ventricular band. Esophagos- 
 copy ujion the struggling, resistant patient whose pharyngoesophageal 
 musculature is in a state of spasm, is, in the hands of the less skillful, 
 not without risk unless care is exercised. The skillful esophagoscopist 
 will do it without the slightest danger. The ordinary risks of anesthesia 
 are very much enhanced by risks of respiratory arrest, be this from 
 reflex inhibition or mechanical obstruction of the trachea from the bulk 
 of the tube or of the foreign body or both, or from other causes. Spas- 
 tic conditions of the hypo-pharyngeal and esophageal musculature, 
 whether from the presence of a foreign bodv or other causes, are com- 
 ])letely relaxed by general anesthesia. For esophagoscojiv the author 
 would ad\ise, if any anesthesia is desired, ether insufflation with the 
 Elsberg apparatus (Fig. 57 ) because it introduces an element of safety 
 which has never ])ertained to esophagoscopy under general anesthesia 
 before, except in the hands of the most skillful. As elsewhere men- 
 tioned, there have been in the practice of various operators a numlier of 
 deaths on the table from arrest of respiration during esophagosco]5v un- 
 der general anesthesia. This occurred es])ecianv in foreign-bodv cases 
 where the bulk of the tube and the Inilk oi the foreign body together com- 
 liressed the trachea when the esophagoscope over-rode the foreign body. 
 The author is not prepared to advocate the Elsberg anesthesia, or any oth- 
 er method, to overcome the faults of technic in esophagoscopy ; but it cer- 
 tainh insures safety, so far as respiratory arrest is concerned, to have
 
 ANESTiiKsiA loR PKuouAi, i:Nnnscopv. 
 
 f)l 
 
 a silk woven catheter in the traclica insnring the supplNini; of air to 
 the hnigs. ami assuring the impossibiHty of complete obliteration of the 
 tracheal lumen, for enough lumen must exist at both sides of the tube 
 to permit the return-flow of air. The author does not hesitate to say to 
 those who wish to use general anesthesia for esophagoscopy that a death 
 on the table is practically impossible with ether insufflation. Of course, 
 the presence of the catheter in the trachea would render possible trauma 
 by the tube moutl;. but only liy the grossest technical faultiness. 
 
 In man_\- cases of foreign body in the esophagus, the foreign body 
 is [ircvented from going downward by muscular contractions. There- 
 fore, if a general anesthetic is given, the relaxation of this clonic con- 
 traction by the anesthetic permits the foreign body to escape downward. 
 The author believes this to be one of the reasons whv it has so rarelv 
 
 Fi(f. 57. Mlsljcrg apparatus for intratracheal iiisutTlation ether anesthesia. 
 
 happened in the I'ittsburgh Clinic that a foreign body has been lost 
 downward. In the absence of anesthesia, the ])rcsence of the tul)e ex- 
 cites still greater spasmodic contractions of the esophageal wall and the 
 foreign body is held all the more tightly, which gives the operator a 
 good chance to approach it with the lube and seize it wilii the forceps. 
 Out of 20(i cases, only S went down, and of these, only 3 went down 
 after the commencement of the esophagoscopy. Of the :?, 2 were under 
 general anesthesia, which leaves but a single case where a foreign body 
 escaped dounw.inl during esophagoscopy witlunu anesthesia, general or 
 local. 
 
 In tlie l;ist loT bronchoscopies and esophagoscopies fur furcign bodies 
 in children under (i years of age, done in the I'iltsburgh Clinic, no an- 
 esthetic, general or local, has been used. .\ number of adolescent and 
 adult cases \v,\\v been done also without anesthesia, general or local.
 
 fi2 ANESTHESIA FOR PERORAL ENDOSCOPY. 
 
 Ten of the cases have been in the children of physicians, every one of 
 whom expressed his delight that no anesthetic was used, and in each 
 instance the physician was present at the removal of the foreign body 
 from his own child. Surely this is the best evidence that there is no 
 very severe ordeal connected with bronchoscopy and esophagoscopy with- 
 out anesthesia. There is no question in ihe author's mind but that all 
 forms of anesthesia, general or local, introduce a great element of dan- 
 ger to the handling of foreign-body cases in children, more especially 
 when chloroform is used. In adults, with ether, the risk in cases free 
 from dyspnea is probably very slight. The ordinary risks of chloro- 
 form anesthesia are enormously increased in esophagoscopy, for which 
 chloroform is absolutely contra-indicated. 
 
 The author has had one post-operative death from general anes- 
 thesia in endoscopy. A man of 46 died about one week after direct 
 laryngoscopy for the removal of a laryngeal neoplasm. There was a 
 gangrenous bronchitis due to delayed chloroform poisoning. He had an 
 old bronchial history. As he took ether badly, chloroform was substi- 
 tuted. Not doing well with this, the anesthesia was abandoned, the 
 operation being done without an anesthetic. As there was no instru- 
 mentation whatever below the laryn.x, and as the death occurred a week 
 after the laryngeal operation, the author cannot see that endoscopy can 
 be blamed. It is the only death directly or indirectlv due to general 
 anesthesia in the author's entire endoscopic experience. The only rea- 
 son for using a general anesthetic was that the small growth was very 
 vascular and edematous, hence, shrunk so as to be invisible when cocain- 
 ized. The comparatively trixial nature of the growth rendered the oc- 
 currence all the more distressing. The author had one toxic death from 
 idiosj'ncrasy to cocaine in a child of 4 years. Death occurred after rhyth- 
 mic convulsions three hours after removal of laryngeal Dapillomata for 
 which an 8 per cent cocaine solution had been used. These two deaths 
 both occurred in the early years of peroral endoscopy and led the author 
 to develop to the utmost the means of working without anesthesia, and 
 he was astonished at the utter Heedlessness of any anesthetic in children. 
 
 As all opium derivatives have a toxic effect upon the respiratory 
 center, their use in any case in which chloroform is expected to be given 
 is distinctly contra-indicated lest the synergistic toxic effect cause re- 
 spiratory arrest. If the endoscopist insists on their use, he should be 
 prepared promptly to apply bronchoscopic oxygen insufflation, for ordi- 
 nary artificial respiration is illogical and useless when the respiratory 
 center is paralyzed with drugs. As children are particularly susceptible 
 to the action of opium derivatives, the danger is particularly great, and 
 there is very good evidence to show that some of the unexplained deaths
 
 ANESTHESIA FOR I'KROKAI, ENDOSCOPY. 
 
 63 
 
 after hronchoscopy, which, by the way, always have occurred in cases 
 in which an anesthetic had been given, were probably due to paralysis 
 of the respiratory center by the combined toxic action of the chloroform 
 with morphine or with codein. Atropin counteracts the effect of mor- 
 phine to some extent in this direction, but it would seem that to give 
 chloroform, codeine, cocaine, adrenalin, morphine and atropine is loading 
 up the organism with a great many drugs. In the case of children it is 
 an utterly needless lot of drugs, as any one will admit who has seen 
 bronchoscopy in children without anesthesia, general or local. In ado- 
 lescents, morphine may be used in conjunction with ether or the usual 
 
 Fig. 58. Schema illustrating the method of hyoid bone elevation to free the 
 air passages during general anesthesia. 
 
 morphine and atropine hyjiodcrmic combination may be tised, though in 
 uncomjjlicated cases no anesthetic is necessary. In adults this combina- 
 tion is useful especially in difficult foreign-body cases. The use of 
 atropine as advocated by Ingals to lessen secretions during bronchoscopy, 
 not only checks secretions but is a valuable stimulant to both the cardiac 
 and respiratory centers, so that it would seem to be advantageous from 
 a number of points of view. The safety of scopolamine is unproven. 
 
 When using general anesthesia and the patient does not take it 
 well, the best thing to do is promptly to insert a silk-woven catheter and
 
 04 ANESTHESIA FOR PERORAL ENDOSCOPY. 
 
 proceed witli the anesthesia by ether insufflation with th.e Elsberg or 
 similar apparatus. If for any reason this is considered undesirable or 
 the apparatus is not at hand, the breathing may be promptly cleared by 
 hyoid-bone elevation, using either the direct laryngoscope or the fore- 
 finger. Fig. ."jS, as described by Dr. Ellen J. Patterson (I!ib. 42!0, the 
 head being forced into extreme extension. This extension of itself will 
 usually clear the airway as shown by Hobart A. Hare. 
 
 An interesting case of tracheal obstruction by an aneurysmal com- 
 pression, plus a small mass of mucus is reported by Pratt (Uib. -iSG). 
 During anesthesia the patient became cyanotic in spite of violent respira- 
 tory^ muscular activity. Insertion of an intratracheal tube gave immediate 
 relief. No case of paralysis of the larynx, even if only monolateral, should 
 be given a general anesthetic except by intratracheal insufflation. If this 
 cannot be arranged, the patient sliould be tracheotomized. Hence, every 
 adult patient should be examined with the throat mirror before anesthesia, 
 and the necessity becomes doubly imperative before goitre operations. A 
 number of fatalities have occurred from neglect of this precaution. 
 
 Da\is reports the use of the intra-muscular injection of ether into 
 the buttock of a child primarily rendered unconscious by ethylchlorid. 
 
 Joseph A. Stucky and William Stuckv have used rectal ether anes- 
 thesia with excellent results. 
 
 ADDITIONAL NOTES ON LOCAL ANESTHESIA. 
 
 If local anesthesia be used in children, the author urges care and 
 gentleness in its application especially to the subglottic region of children. 
 For direct laryngoscopy in adults, some endoscopists have proposed in- 
 jecting an anesthetic solution with a syringe armed with a hypodermic 
 needle into the laryngeal tissue. This the author believes to be unneces- 
 sary as contact anesthesia will suffice for all cases if the patient's 
 eyes are covered and the operator can get the patient to fix his attention 
 on deep breathing. Some very apprehensive patients will anticipate cough 
 at the contact of the instrument and will cough semi-voluntarily in the 
 absence of a true reflex, if they are allowed to see the instrument enter 
 through the speculum. If it is desired to anesthetize locally for esophagos- 
 copy the best method is to make a preliminary application of an S per 
 cent solution over the epiglottis and into the larj'ngopharynx with cotton 
 on the Sajous' applicator. Then either the laryngeal or the esophageal 
 speculum is passed and the right pyriform sinus is swabbed once with a 
 20 per cent solution on a gauze sponge held in a straight sponge-holder 
 and allowed to remain for about a minute. Examination mav begin one 
 minute later. Cocaine tablets may be sterilized by placing a formalde- 
 hyde pastille in the bottom of a bottle in which the tablets are kept.
 
 ANF.STHKSIA TOR l'i:i;OKAl. KNDOSCOPY. C5 
 
 . hiestlicsia for the use of the esopliojieal speculiiiii. \utv llie use of 
 the eso])li;igeal speculum, local anesthesia is not necessary, but lessens 
 the slight discomfort. General anesthesia is not necessary, l)ut if deep, 
 affords a very much licttcr \ie\v of the ujjper end of the esophagus be- 
 cause it prevents spasm of the inferior constrictor and of the esophageal 
 musculature in general. Tlie autiior's custom, however, is to use no 
 anesthesia, general or local, in cither adults or children. l'"or local 
 anesthetization, the method just given for esophagoscopy may be used. 
 
 For gastroseopy, no anesthetic, general or local, is needed to enable 
 the skillful esophagoscopist to put the gastroscope into the stomach ; but 
 once there, in the absence of the complete rela.xation of general anesthesia, 
 the gastroscope remains fixed because of the muscular activity of the 
 diaphragmatic musculature. To gain full relaxation of this musculature 
 and of the abdominal wall, in order that the gastroscope mav be freely 
 movable, jirofound anesthesia is esscnti;d. Intratracheal ether insuti'la- 
 tion is most convenient. 
 
 .\n'Kstiii:tizix(', a traciii;ot().mizi;i) i'.\tiknt. 
 
 Xo hesitation need be felt in gi\ing a general anesthetic to a trache- 
 otomized patient so far as the tracheotomic wound is concerned. Such 
 a patient is far safer than one not tracheotomized and there is no trouble 
 with the tongue or the tissues attached to the hyoid bone falling back- 
 ward and downward obstructing breathing. They take the anesthetic 
 quietly. It has been necessary many times for Dr. I'aiterson to remove 
 tonsils from patients under treatment for laryngeal stenosis. In every 
 instance the patient went under ether (|uietly and was kept fully under 
 until the operation was completed, all \c5sels twisted and oozing stop])ed. 
 
 The technic is simjile. .\ fold of gauze is laid o\er the tracheotomy 
 cannula and. if the laryngeal stenosis is not complete, another over the 
 mouth. The etlier is dropped upon both pieces so tli;il no matter which 
 way air is taken in, it carries the ether with it. It is necessary to see 
 that a good stout tape is securely attached to the cannula and tied back 
 of the neck in the regular way. One assistant or nurse trained to tracheal 
 work should be stationed to give undivided attention to th.c c.innnla ;ind 
 secretions coming from it. 
 
 INSUFFLATION ANKSTIIKSIA. 
 
 The experiments of Melzer and .Auer and the developments bv hlls- 
 berg, janeway. Carrel. Ouinby, Cotton, Robinson, and others have placed 
 intratracheal insufflation anesthesia on ;i tlrm. scientific and practical basis. 
 Tli\rotom\ can be readilv done under local anesthesia bv those who fullv
 
 66 
 
 ANESTHKSIA FOR PF.ROKAI, EXDOSCOPY. 
 
 understand the technic of infiltration. Much time, however, will be 
 saved by insufflation anesthesia ; and the strong return-flow keeps the 
 blood and secretions from gaining an entrance to the lower air-passages. 
 This return-flow is in ever\- way more advantageous for the purpose 
 than the use of the tampon cannula, the Trendelenberg position, or even 
 the excellent plan of JMoure, using the ordinary cannula with a gauze 
 tampon in place above the cannula. It is surprising how little room the 
 insufflation catheter introduced through the mouth requires in the opened 
 lan,nx. It lies close along the posterior wall in a region which it is not 
 necessary to invade, because thyrotomy is apt to be unsuccessful in 
 
 Fig. sg. Insufflation ether anesthesia with the Elsberg apparatus in the clinic 
 of Dr. Otto C. Gaub. The anesthetist, Dr. Wade Elphinstone, has exposed the 
 larynx and is about to introduce the silk woven catheter in a case of head surgery. 
 Note the full extension with the head on the table. 
 
 malignancy if the involvement has reached the party wall. Should it be 
 necessary in benign conditions to operate upon this wall, it is very easy 
 to displace the catheter sideways. In malignant cases, if it is found that 
 the growth is not removable by thyrotomy and that a laryngectomy is 
 necessary, it is very easy, after amputating the trachea, to insert the 
 insufflation catheter into the cut-end of the trachea and thus earn,- out a 
 complete laryngectomy with the anesthetist entirely out of the way and 
 with no loss of time. Dr. Otto C. Gaub and Dr. W. P. Barndollar have
 
 ANESTHKSIA J-OR PERORAI, l-.NDOSCOPY. G7 
 
 demoiistratt'd the great advantage of the intratracheal insulllation method 
 of anesthesia in the extirpation of a nasopharyngeal fibroma, which was 
 so large that it pressed the soft palate forward on the tongue and pro- 
 duced dangerous dyspnea. Tf to this had been added the free flow of 
 blood usual in such cases, the i)atient would have been asphyxiated. On 
 the contrary, in this case, from the moment the insufflation was started 
 the patient's color was good. All blood and clots came back out of the 
 mouth and the operation required only a few minutes because it was un- 
 interrupted. The presence of the catheter in the mouth produced no in- 
 convenience whatever. The day of tracheotomy preliminary to the extir- 
 pation of nasopharyngeal fibromata is past. In all prolonged, bloody, 
 nasal. ])haryngeai. buccal, and laryngeal operations insufflation ether an- 
 esthesia diminishes the time of operation at least three-fourths. In 
 aural, ophthalmic, and all forms of general head and neck surgery the 
 distant removal of the anesthetist from the field is not only a time-saving 
 convenience, but it eliminates a serious infective risk. In general sur- 
 gical operations requiring a jirone jiosition of the patient, insufflation an- 
 esthesia is ideal. In the short, thick-necked, alcoholic "full-blooded'' type 
 of patient that ordinarily behaves so badly under ether by the open 
 method, insufflation anesthesia gives a quiet and perfect anesthesia impos- 
 sible by any other means. 
 
 All the foregoing classes of cases are jjarticularly the sphere of in- 
 sufflation anesthesia ; but it is an ideal method for anesthesia in any sort 
 of case, because of its safety and its precision and minimization of dosage, 
 Meltzer refers to the mouth, pharynx, larynx, and trachea as the "death 
 space,"' a particularly expressive term, for there can be no doubt what- 
 ever that most of the deaths from anesthesia have been due, directly or 
 indirectly, to purely mechanical obstruction in these regions. In re- 
 suscitation from respiratory arrest, or collapse, or cardiac failure, it is 
 tliis '"death space" which is hardest to fight because of the difficulty oi 
 kee[)ing up artificial res])irati()n in a good and efficient way in the flabby 
 state in which the tt)ngue and all the tissues attached to the hyoid bone 
 are. at such times. Some sort of artificial airway is essential. In in- 
 sulllation anestliesia the "death space" is entirely eliminated and acci- 
 dents presented. In regard to the efTect on the mucosa of the air pas- 
 sages, ihc .lutluir is .ible to state from post-anesthetic laryngoscopy in so 
 cases that there is no reaction in the larynx from the ])resence of the 
 insufflation tube, even in a jirolonged anesthesia by insufflation. In quite 
 a luunbcr of the cases anestlu-ti/ed by the (irdinary open mclhix] there 
 has been quite a great deal of local laryngeal reaction, probably froiu 
 ether mucus bubbling back and forth in the lar\-nx. so that from an ob- 
 ser\a1ion of these 80 cases the .lutlmr is prepared to s.-iy that there is
 
 68 ANKSTIIESIA FOR PEKORAL ENDOSCOPY. 
 
 less irritation of the lar}'nx from an intra-traciieal insufflation than from 
 an anesthesia of corresponding duration bv the open method. In the 
 mucosa of the trachea and bronchi in sixteen cases there was less mucosal 
 reddening, and not nearly as much mucus as is usually seen in patients 
 etherized by the open method. Bronchoscopic observations of the author 
 have proven that the "ether mucus" of the ordinary open method of ad- 
 ministration is from the salivary glands and not from the tracheo-bron- 
 chial mucosa. True, patients etherized by the open method are found 
 to have their trachea and bronchi full of mucus, but it has been aspirated 
 from above o\\ing to abolition of the cough-reflex. The management 
 of the apparatus varies so much with the form of apparatus, and 
 the apparatus have become so numerous, that the technical manage- 
 ment of each cannot be given here. Explicit directions reprinted from 
 the writings of the surgeons who have devised the instruments are sup- 
 plied by the makers. The dosage is regulated according to the effect on 
 pulse respiration, reflexes, color of skin, etc., as in any other method 
 of administration. The great difference, however, is the quickness of 
 response to increase, diminution, or withdrawal of the ether-content of 
 the insufflated air. The anesthesia can be deepened, shallowed, or the 
 patient brought out with a promptness and precision that seems incred- 
 ible to those accustomed to the slow response inevitable with other meth- 
 ods in all of which control is befogged by the unknown and unknowable 
 residual ether-content of the air and food passages. \\'ith insufflation 
 there is no fluid ether anywhere in the body, except that already absorbed 
 into the blood, and as soon as the ether is shut oiT, the warmed air-cur- 
 rent blows out the ether-vapor from the air passages. The author's first 
 experience with insufflation anesthesia was with the insufflation attach- 
 ment to the bronchoscope (Fig. K) suggested to the author by Dr. T. 
 Drysdale Buchanan. (Bib. 22!)). This was for the insufflation of chloro- 
 form during bronchoscopy and was intended simply to carry on anesthesia 
 without interruption of the work through the bronchoscope, for which 
 purpose it is ideal. It was not intended for a method of anesthesia for 
 other procedures. 
 
 Tcchnic of insertion of intnitraclical insufflation tubes.* Practical- 
 ly all authorities are now agreed that the larynx should lie inspected be- 
 fore the insertion of the insufflation catheter or tube, for the purpose of 
 ascertaining whether or not there is disease present in the larynx, and 
 also to determine the size of the larynx, so that the size of the insufflation 
 tube may be selected accordingly, in order to make sure that there is an 
 ample laryngeal lumen around the tube for the return-flow. Not only 
 
 *This section contains liberal (luotations from the author's romniunication to 
 the riinical Congress of Surgeons of North America. Nov.. 1313 (Bib. 2G6).
 
 ANESTHESIA rOK PEUOKAI. i:xnnS0OPY. 69 
 
 do the sizes of the hirynges vary in normal incH\ ichials, but the laryngeal 
 lumen may be modified by lesions present or ])ast. There is another 
 reason why the larynx should be inspected ; namely, throughout the whole 
 category of diseases to which human flesh is heir, it is a frequent thing 
 for patients to date comi)laints from some particular period, accident 
 or operation in cases in which the physician or surgeon is absolutely cer- 
 tain tJiat the disease existed long before the incident blamed by the 
 patient. In view of this, it Iiehooves the surgeon to know whether the 
 larynx is diseased or not at the time liie insufllation catheter is inserted. 
 ( )ne such case has occurred where the patient dated laryngeal trouble 
 from the taking of an anesthetic given by the ordinary open method. 
 The ;iuthor's own case-records and sketches showed that the lar\nx had 
 been the seat of an infiltration of tuberculous origin for years before 
 the anesthetic was given, showing that the anesthesia was in no way re- 
 sponsible, and showing, also, the necessity of knowing the state of the 
 larynx beforehand. Only one thing seems to deter anyone from using 
 the method advocated by Elsl)erg of insjiecting the larynx and passing 
 the catheter or tube by sight. This is the lack of confidence in the abilitN' 
 promptly and skillfully to expose the larynx with the laryngeal speculun^ 
 Xo one cai)able of gi\ing an anesthetic should hesitate for one moment 
 abiiut this procedure, if he will take the trouble to pay attention to a 
 tew ])oints. 
 
 Rt"I.i;S FOR INSi:RTinX ni' IXSfl'FI.ATION ANlCSTlt ICSI.V. 
 
 1 . The patient should be fully under the anesthetic by the open 
 method so as to get full relaxation of the muscles of the neck. 
 
 ■-'. The patient's liead must be in full extension with the verte.x 
 lirmiy pushed down toward the feet of the patient, so as to throw the 
 neck ui)ward and bring the occi[iut down as close as possible bencith the 
 cervical vertebrae. 
 
 '■'>. Xo gag should be used, because tlie i)atieiit should be sunicienlly 
 anesthetized not to need a gag, .ind because wide gagging defeats the ex- 
 posure of the laryn.x by jamming down the mandible. 
 
 4. The cjjiglottis must be identified l)efore it is passed. 
 
 5. The S])eculum must pass sufficiently far below the lip of tlu- epi- 
 glottis so that the latter will not slip. 
 
 (!. Too dee]) insertion must be avoided, as in this case the speculum 
 goes jjosteiior to the cricoid, and the cricoid is lifted, exposing the nujulh 
 of the esophagus, which is bewildering until sufiicient education oi the 
 eye enables the operator to recognize the landmarks. 
 
 The most important thing of all is the position of the patient, ,-uicl 
 next to that comes recognition of the epiglottis, and next the proper mo- 
 tion of lifting the hyoid bone to expose the larynx.
 
 70 ANESTHESIA FOR PKRORAI, ENDOSCOPY. 
 
 The correct position will be understood by reference to the illus- 
 trations. In Fig. GO, the patient is placed on a pillow in a natural posi- 
 tion. The larynx can readilv be examined in this position, if it is de- 
 sired merely to inspect it, and is useful for laryngeal diagnosis and some 
 endolaryngeal oi<erations ; but for the insertion of an insufflation tube, 
 bronchoscope, or other instrument, it is absolutely necessary for any but 
 the most expert to have the head in full extension. It has been customary 
 to draw the head over the table to gain the full extension in the Boyce 
 position, and for bronchoscopy this is needed for the purpose of moving 
 
 Fig. 60. 
 
 Fig. 61. 
 
 Fig. 62. 
 
 Fig. 60. Photograph of patient with head upon a pillow, the hca<l fle.xed. In 
 this position it is easy to examine the larynx with the laryngoscope for diagnosis, 
 but the larynx will not be exposed in a line with the tracheal axis so that this posi- 
 tion is not adapted to the passing of tubes through the laryngoscope. 
 
 Fig. 61. The pillow is removed, the head is flat on the table and the anesthetist 
 is be.ginning to force the head into the extended position. The thumbs are on the 
 forehead and the lingers are at the side of the head. The direction of motion is 
 shown by the dart. 
 
 Fig. 62. The anesthetist is lifting with the tip of the laryngoscope in the direc- 
 tion of the dart. The laryngoscope is always held in the left hand. The right hand, 
 of which the index has been protecting the upper lip, has now received the catheter 
 from the nurse. The head must be in lull extension. 
 
 the head and the bronchosco])e abotit so as to enter the particular bronchus 
 desired. But for the insertion of the insufflation tube, it is quite unneces- 
 sary to have the head extend beyond the table, and in fact it is unde- 
 sirable. The author's "elbow rest position," so called because the oper- 
 ator's left elbow can be rested upon the table during long endo-laryngeal 
 operations, is admirably adapted to the introduction of insufflation tubes. 
 All that is necessary to do to the patient is to remove the pillow, place the 
 thumb of each hand (as shown in Fig. (>1 ) on the forehead of the patient 
 with the hands at the sides of the head and then force the forehead vigor- 
 ously downward and backward, causing an anterior movement of the
 
 ANESTHESIA TOR I'KKOKAI, KXDOSCOPY. 71 
 
 skull nil the atlas and throw inj; all the eerxical vertebrae forward (upward 
 in the reeumhent position). The effect of this is to throw the liyoid bone 
 and all the tissues of the neck, including the larynx, high up and to ele- 
 vate the tongue. The neck and shoulders are arched up away from the 
 table. In a fully relaxed [)atient. it is not necessary for an assistant to 
 steady the head in this position, while the anesthetist takes the speculum 
 always in the left hand, his right index being used to ])ull the upper lip 
 of the patient out of the way so that the li]) will not be pinched between 
 the speculum and the upper teeth. The spatular end of the speculum is 
 now inserted posteriorly to the tongue over the dorsum of which it is 
 passed until the epiglottis comes into view. The spatular end is made 
 to pass posteriorlv to the tip of the epiglottis, and inserting the speculum 
 a distance of, on the average, about 1 cm., the hyoid bone and all of the 
 attached tissues are lifted by a motion which is best expressed as the 
 suspension of the head of the patient on the epiglottis by the tip of the 
 spatular end of the laryngeal speculum. Great care is necessary at this 
 point not to use the upper teeth as a fulcrum upon which to pry upward 
 with the tip. The motion is rather the lifting of the epiglottis and es- 
 pecially the hyoid bone by the tip of the instrument just as if it were 
 desired to lift the patient's neck upward. Hyoid bone elevation opens 
 the laryngeal door. After the larynx is exposed, the right hand releases 
 the upper lip, which is now safe, and the catheter of the desired size is 
 handed to the anesthestist by the nurse and the introduction is simple 
 and easy, because the trachea is in a straight line with the laryngeal spec- 
 ulum. This is the great advantage of the extended position with the 
 head on the table. At first sight, it might be thought that the speculum, 
 as shown in Fig. tiS, could not be in line with the axis of the trachea. It 
 seems to be the erroneous conception quite prevalent among the profes- 
 sion that the trachea is peri)endicular in the neck and chest. .\s a matter 
 of fact, it enters the chest in a direction backward as well as downward. 
 as illustrated schematically in Fig. 64, so that in the extended position 
 I)ro])er for the exposure of the larynx and the insertion of anv sort of 
 tube into the trachea, the axis of the speculum, as shown in h'ig. (!2, is 
 I)recisely in line. This must be remembered in placing the patient in 
 position, but for the insertion of the speculum it is well to forget it and 
 remember only that the motion is a strong lifting of the //'/' of the 
 sj)eculum, as shown in Fig. (1"^. In some patients after the introduction 
 of the catheter there may be a large amoinit of thick tenacious secretion 
 enter the catheler which may occlude respiration through the catheter, 
 so that the hand held in front of it does not receive the exjiiratorv blast, 
 leading to the impression that the catheter is not in the trachea. If there 
 is any doubt on this point it is better to insert the specuhun and to lift
 
 72 ANESTHESIA FOR PERORAL ENDOSCOPY. 
 
 the epiglottis and note particularly that the arytenoid eminences are 
 posterior to the catheter. Oi course in cases in which the patient is not 
 deeply anestlietized cough will free the catheter but when the cough-re- 
 tlex is abolished the ]iatient will breathe on each side of the occluded 
 catheter through the lumen of which no air will emerge at ordinary 
 resoiratory pressure. If occluded a fresh catheter may be substituted, but 
 in most instances probably no harm whatever would come from inserting 
 the nozzle of the insufflation apparatus and proceeding with the insuffla- 
 tion anesthesia in the regular way. because the catheter will be blown 
 clear by the insufflation pressure and brought out liy the return flow. 
 The reason why the expiratory current does not clear it is that there is 
 so much room for expiratory air around the catheter that there is very 
 little pressure on the secretion in the catheter. The author recently in- 
 sufflated a patient with bilateral laryngeal paralysis. He put in an extra 
 tube for the return-flow but found it quite unnecessary, for, even with 
 the tracheotomic wound closed with the finger, there was ample return- 
 flow between the flaccid cords which flapped in the breeze of the return- 
 current. He had feared that in the absence of the inspiratory abducting 
 excursion there might be some obstruction in the larynx and the tracheo- 
 tomic wound was obstructed witli granulations. For the introduction of 
 insufflation tubes the side-opening laryngoscope (Fig. 1')) has some ad- 
 \'antages. After the catheter is inserted, the laryngoscope may be re- 
 moved sideways tlimugh the lateral opening. After skill in direct laryn- 
 goscopy is acquired, the slide may be left ot¥ entirely, but at first one is 
 apt to he troubled by the tongue curling in and obstructing the view. 
 This is [irevented by passing the speculum to the riglit of the tongue, thus 
 lea\ing the tongue on the closed side of the speculum. The author's per- 
 sonal preference is for the regular laryngosco])e. Fig. 14. 
 
 ^lention is made above of deep anesthesia. ( )nce the knack is ac- 
 (|uired no anesthetic whatever, general or local, is needed to expose the 
 larynx in any patient ; btit to the beginner it simplifies the acquiring of 
 the knack of direct laryngoscopy to abolish the reflexes of vomiturition 
 and coughing, and to abolish entirely the antagonism of certain muscles 
 attached to the hyoid bone. In the author's clinic an anesthetic, general 
 or local, is never used for direct laryngoscopy, bronchoscopy or esophagos- 
 copy in any child under (i years of age, and rarely in adults, except for 
 a few special procedures ; but for insufflation anesthesia, the jiatient may 
 as well be jiut comjiletely under by the open method as only partially. 
 To cocainize the larynx for the insertion of an insufflation tube to help 
 along in partial anesthesia is an utterly needless waste of lime.
 
 CHAPTER V. 
 
 Bronchospic Oxygen Insufflation. 
 
 Broiichoscopic oxygen insiifllatiuit. Some experiments made upon 
 the clog by Dr. Otto C. ("lauh, with the assistance of the author, showed 
 clearly that the lunt; which ordinaril}' collapses when the pleural cavity 
 is opened may he intlated with oxygen, deflated or held ])artiallv inflated, 
 by the hronchoscojjist at the command of the surgeon. Oxygen can be 
 admitted to the unoperated lung and a constant return-flow maintained 
 so that the \ilal pulmonar\ hemic changes go on normally and pleural 
 shock is also lessened. Fiu'thermore. the lung on the ojjerated side can 
 be allowed to collajise without danger to the patient, thus allowing the 
 surgeon ample room for work with the hands and instriuuents within the 
 thorax. Again, indejiendent of inilation and deflation a constant supply 
 of oxygen is kejit streaming through the lungs supplying every need, as 
 shown by the ])ink color of the blood. Tiie usefulness of this procedure 
 so far as thoracotomy is concerned has disappeared since the method of 
 intratracheal insufflation anesthesia has been introduced by Melzer and 
 .\ner and developed by Elsberg, Janeway and others; but for the liron- 
 choscopist, the bronchoscoi)ic oxygen insufllation is a life-saving pro- 
 cedure always at immediate command. The method is simple and is 
 shown .schematically in Fig. 63. The bronchoscope preferably of small 
 size ( T nmi. for adults, 4 mm. for children) is inserted through the glot- 
 tis, 'i'he tube from the oxygen tank is attached to the anesthesia-inlet 
 of the bronchoscope and the oxygen turned on at the tank \al\c (V). 
 There is no danger from over-pressure because the bronchoscope is open. 
 The operator's thumb (T) must never be placed over the proximal open- 
 ing of the bronchoscope, because of the danger of over-jjressurc. The 
 fundamental law which nuist be constantly before the luind is that of 
 C'rile. In brief, the intra])ulmonary pressure must not exceed the capil- 
 lary lilooil pressure or the compression of the capillaries and consequent 
 ischemia will prove fatal. This cannot occur if the orifice of the broncho- 
 scope is open because there is such an ample return-flow through the
 
 74 
 
 BRONCHOSCOPIC OXYCEN INSUFFLATION. 
 
 lironclioscopic lumen that absolute safety from over-pressure is assured. 
 Of course tlie lungs cannot be thus forcibly inflated, and the usual arm- 
 motion artificial respiration must be used in addition in this form of 
 bronchoscopic oxygen insulHation. But the bronchoscope establishes an 
 artificial airway which is stronglv charged with oxygen and which can- 
 not be obstructed by dropping back of the tongue. A small esophago- 
 scope may be used instead of the bronchoscope, the oxygen tubing from 
 the tank being attached to the drainage outlet. The drainage canal will 
 thus carry oxygen right down to the bifurcation. Nitrite of amyl pearls 
 should be carried in every bronchoscope box as amyl nitrite is the most 
 
 Fig. 63. Schema showing bronchoscopic oxygen insufflation. The broncho- 
 scope is in the trachea. Oxygen enters by the small branch tube and is taken in 
 by natural or artificial respiratory movements. If an esophagoscope is used the 
 oxygen can be blown in through the auxilliary drainage canal to the distal end of 
 the esophagoscope. This is safe. The lungs could be inflated by momentarily clos- 
 ing the escape by putting the thumb, T, over the proximal end of the bronchoscope 
 alternately releasing it, but this would be a very dangerous procedure unless over- 
 pressure be carefully guarded against. If preferred, the independent drainage tube 
 used for aspiration can be inserted through the bronchoscope. 
 
 promptly available stimulant in such cases. A pearl may be broken in a 
 tuft of cotton and thrown, cotton and all, into the wash bottle of the 
 oxygen tank. There is only from two to three minutes between the 
 respiratory and the cardiac arrest, so that in cases of serious respiratory 
 arrest in which the operator does not feel confidence in the promptness 
 and certainty of his bronchoscopic introductory technic, it is far safer to 
 do an emergency tracheotomy, dilate the wound, crack an amyl nitrite 
 pearl in cotton, hold the cotton over the wound and blow oxygen past 
 the cotton into the trachea, while an assistant performs artificial respir- 
 ation. In this case it is necessary for the operator to stand at the head-
 
 BKOXCnOSCOI'IC OXVGEX INSUFFLATION. 75 
 
 end of the table facing the patient's feet so as not to interfere with the 
 arm movements. The great drawback to machines for artificial respira- 
 tion using masks is that the vocal cords, because of their shape, else- 
 were shown, have a natural tendency to be forced shut l>y the in-going 
 blast, and because of the pharyngo-laryngo-faucial danger-zone. The 
 latter can be overcome to a great extent, in using the mask, but the laryn- 
 geal closure cannot. I'oth danger-zones are very much increased by 
 the flaccid condition of the parts in impending death from res- 
 piratory arrest; but this same flaccidity is a great advantage in the peroral 
 insertion of a bronchoscope because of the associated total absence of 
 spasm. When a tube is inserted into the trachea for the insufflation of 
 oxygen, conditions are ideal because there is no obstruction to the return- 
 flow such as there is to the in-flow. This does not mean that there is no 
 danger from excessive plus pressure, which must be carefully guarded 
 against : nor should any of the foregoing be taken as a criticism of ma- 
 chines of pulmotor type. Such machines are life-savers of the greatest 
 value, because they can be used by anyone with but little instruction, 
 without the training necessary for the insertion of an intratracheal tube. 
 Vet this does not alter the fact that intratracheal oxygen insufflation is 
 ideal anrl everv'one who has to deal with resjiiratory arrest should be 
 taught the technic of laryngeal exposure for intratracheal insufllation, 
 because the visual method is the only one which is certain under all cc)n- 
 ditions. For instance, the author, in one of our hospitals was called into 
 an adjoining operating room, where a surgeon and his assistants lia<l 
 tried forced mask resi>iratian, then tracheal intubation by blind method. 
 The mask method had given relief for a time but the patient had grad- 
 ually become unconscious and cyanotic. The surgeon's assistant was an 
 expert at blind intubation and could not understand his inability to in- 
 tubate in this instance. The author took with him his larxngoscope and 
 exposure of tlu' larynx revealed occlusion with a grayish mass which 
 proved to be meat. Intratracheal oxygen insufflation after removal of 
 the meat kept the man alive until he could be trusted to do his own 
 breathing. The man was in a state of profound alcoholism when brought 
 in from the gutter in front of the hospital and doubtless the meat had 
 been vomited. That the respirator machine had forced the meat farther 
 into the larynx is no criticism against the machine for the general run of 
 cases; and the surgeon, had a lar\ngoscopist not been available, would 
 have done a tracheotomy, with, doubtless, an equally happy result; yet 
 this does not lessen the force of the lesson that in cases of respiratory 
 arrest the fundamental rec|uirement is to see that the larynx is free from 
 obstruction. If this laryngeal inspection required special aptitude the 
 author would not feel like urging it so strongly; but anyone capable of
 
 76 BKoxciuisconc oxyckn insufflation. 
 
 dealing with rfS])iratory arrest at all can b\ practice acquire the ability 
 to inspect any case, and the easiest of all cases is the one of respiratory 
 arrest, because of the total absence of spasm. Such a patient is just like 
 a cadaver and practice upon the cadaver is excellent training for this 
 work. There is the same insertion of the direct laryngoscope and the 
 raising and suspension of the limp head on the beak of the spatular end. 
 the operator being in the standing position for a patient on a table, and 
 kneeling on the floor, for a patient recumbent on the floor. Of course 
 the cadaverous limpness and ashv blue-blackness of the mucosa does not 
 conduce to the operator's equanimity, but the confidence in his ability 
 promptly to expose and inspect the larynx and to catheterize the trachea, 
 which comes with practice, will meet the emergency. Life-saving et^c- 
 iency demands that every well-equipped hospital shall have at least one 
 man trained for this emergency work.
 
 CHAPTER VI. 
 
 Position of the Patient for Peroral Endoscopy. 
 
 General considerations. The position of the patient varies with the 
 age of the patient, the part to be examined, the purpose of the examina- 
 tion and especially with the personal equation of the operator. J'rac- 
 tically all jirocedurcs nf the laryngologist other than endoscopy are done 
 "face to face" with the patient. When the patient is dorsally recumbent 
 nil the interior anatomy seems strangely unfamiliar; and all the more so 
 liecause the book illustrations, which uncnnsciousl_\- form the basis of 
 mental [liclures. have never sliown the parts in this position. Jt is the 
 effort of this l>ook to supply this need as to illustrations, and to en- 
 courage otliers to practice diligcntlv to overcome tlie ])reference for the 
 sitting position and for the exceedingly awkward lateral recumbent po- 
 sition. Once the habit of working in the recumbent position has been 
 ac(|uired, better work can Ije done in both adults and children because of 
 the greater ease with which secretions and foreign bodies are removed 
 unopposed by gravitx'. In children we have the added reason of greater 
 controllability: not but that a child can be lu-ld as is usu;d ( ihough not 
 necessarily desirable) for laryngeal intubation; but harm may l)e done 
 if the child is not perfectly controlled. There is no upright control that 
 comi)arcs with the fixity of the child held down on a well padded fiat 
 table top. In dyspneic cases, should tracheotomy become necessary, 
 the bronchoscope can be inserted for breathing, and tlien the child is 
 all ready upon the t;il)le for tracheotomy. 
 
 /;; children from every point of view, therefore, it is desirable, for 
 e\ery form of peroral endoscopy, to use the dorsally recumbent position, 
 which, if correctly posed, is much easier for both patient and o])eralor 
 than the lateral. 
 
 The lateral position lor bronchoscopy and esophagoscopw in cither 
 adults or children, has found but little favor in America. Its onK- real 
 advantage is the facility with \\bicli secretions (lr;iin Irum the lowenuost
 
 78 POSITION OF THE PATIENT FOR PERORAL ENDOSCOPY. 
 
 corner of the mouth. This can be accomphshed almost as well in the 
 dorsal position with a wick of gauze hanging out over from the pharynx, 
 the outer end the longer. If secretions are too thick to drain by capil- 
 larity, the gauze is frequently replaced by a fresh piece. An aspirating 
 drainage tube of metal (Fig. 24) connected with the author's esophagos- 
 copic aspirator (Fig. 23) is hooked into the lowermost portion of the 
 patient's mouth in bronchoscopy. This rids the mouth of secretions 
 while the patient is in the dorsal position. One thing that has led some 
 endoscopists to think that the lateral position is easier is that in the lat- 
 eral position the operator does not so readily make the mistake of ex- 
 tending the cervical spine instead of extending simply the head upon 
 the atlas. If the operator should stand instead of crouch, in doing a 
 peroral endoscopy upon a patient in the dorsal position, he would have 
 the correct head-position of the patient. 
 
 In foreign-bodx cases, whether in adults or children, no matter where 
 the foreign body is located (even in the fauces or nasopharynx), the 
 patient should always be recumbent, never erect, because in the erect 
 position gravity works against the operator, and the foreign body may 
 reach a deeper point in the air passages than it would in the recumbent 
 position. This is particularlv true of foreign bodies in the larynx and 
 pharynx, which should never be touched unless the patient is in the 
 Trendelenberg position. Quite a large proportion of the foreign bodies 
 in the bronchi that have been sent in to the author, were originally in the 
 larynx, pharjnx. mouth or nasopharynx and fell down when displaced 
 by the attempts of the operator, who first saw the case, to remove the 
 intruder with the patient in the sitting position. 
 
 in adults. For the diagnosis of laryngeal disease and for the re- 
 moval of specimens, or of entire growths, by direct larv^ngoscopy under 
 local anesthesia the sitting position of both patient and operator is the 
 best. In the few cases in which a general anesthetic is needed for direct 
 laryngoscopy the recumbent position is obligatory as wel! as advantag- 
 eous. 
 
 For bronchoscopy for diagnosis, which is practicallv always done 
 under local anesthesia, the adult patient may be sitting. If there is much 
 Secretion to be removed this is somewhat of a disadvantage, but with an 
 active cough-reflex the secretion may be gotten rid of without difficulty, 
 even in bronchiectatic and pulmonary abscess cases. The author's per- 
 sonal preference in such cases is for recumbency. For bronchoscopy for 
 foreign bodies in adults, as before mentioned, the recumbent position is 
 always best. 
 
 For esophagoscopy for diagnosis and treatment, with or without 
 anesthesia, the author's preference is for the recumbent position. It has
 
 POSITION- OF THE PATIENT EOR PERORAI, ENDOSCOPY. 
 
 79 
 
 great advantages in dealing without interrui»tion with the secretions and 
 food debris, so abundant in many cases, and the patient is much more 
 controllable. When a start is made it is a waste of time to withdraw 
 the tube because the patient has slid off the stool or is strangling with 
 secretions which have overflowed into his larynx. 
 
 General prineiples of all positions. The general principles of all 
 useful positions are the same. The author was the first to call the atten- 
 tion of endoscopists to the fact that the trachea and esophagus are not 
 
 Fig. 64. Schematic ilhistrauon of normal position of the intra-thoracic trachea, 
 and also of the entire trachea when the patient is in the correct position for peroral 
 bronchoscopy, such as the original Kirstein position, or that shown in Fig. 70. 
 When the head is thrown backward (as in the usual or in the Rose position) the 
 anterior convexity of the cervical spine is transmitted to the trachea of which the 
 axis is thus deviated. The correct position is produced in the recumbent patient by 
 raising the head. The anterior deviation of the lower third of the esopliagus shows 
 the anatomical basis for tlic autlior's "high-low'' position for esophagoscopy. (Figs. 
 140 to 152). 
 
 perpendicular. Their long axis passes backward as well as downward 
 following the general direction of the thoracic spine (Fig. (il). There- 
 fore, if we throw the patient's head backwards we cause an anterior con- 
 vexity of the cervical spine, and with it the esophagus and trachea, as 
 shown in the radiograph. Fig. GG. The Rose position and the usual in- 
 correctly ajijilied extended position make this extension tbroiighniu ihr 
 entire cervical spine as shown in I'ig. GG. rendering peroral endoscopv
 
 so 
 
 POSITION OF THE PATIKXT FOR PliRORAL EXDOSCOPV. 
 
 Fig. 05. (orrect positiim ol the cervical spine for esopluiguscopy ami bron- 
 choscopy. (Illustration reproduced from author's article, Jour. A. M. A., Sept. 
 25. igog). 
 
 Fig. 66. Curved position of the cervical spine, with anterior convexity, in the 
 Rose position, rendering esophagoscopy and bronchoscopy difficult or impossible. 
 The devious course of the pharynx, laryn.x and trachea are plainly visible. The 
 extension is incorrectly imparted to the whole cervical spine instead of only to the 
 occipito-atloid joint. This is the usual and very faulty conception of the extended 
 position. (Illustration reproduced from author's article. Jnur. A. M. A.. Sept. 23, 
 1909).
 
 POSITION (I'" THE PATIENT FOR PERORAI, ENDOSCOPY. 
 
 81 
 
 extremely dilhcull or impossible, as demonstrated by tbe author years 
 ago (Bib. 23(1). Jn the correctly posed extended position the e.xten.sion 
 is at the occipito-atloid joint, and the cervical spine is strongly inclined 
 forward (upward in the recumbent position as shown in Fig. (!.")). If 
 it is not desired to extend the head the cervical spine nevertheless remains 
 
 Fig. 67. Lateral radiograph of a cliiUl ol 4 >i.'.ir.>, shuuiiij; llic normal direc- 
 tion of the trachea. \ pale streak is seen extending backward as well as down- 
 ward, ending at the foreign body in the right bronchus. There is a narrowing of 
 this streak at the bifurcation, representing a llatlening in mi before backwards. 
 Compare schema, Fig. 64. 
 
 the s;une. W JK-tlur the head is flexed or extended or kenl niidwiiy. the 
 fundament.-d [irinciple of all positions is the aiiteiidr placing of the 
 cervical spine (I'ig. '>'"i). 
 
 Sitliii(/ l^osituni of the adult l^tiliriit for direct lary)i(iosco['y. The 
 orii,'inal jiosition of Kirstein descrii)ed by him 2U years ago, when he 
 originated direct laryngoscopy, contained the essentials of the correct
 
 82 
 
 POSITION OF TirK PATIKNT FOR PERORAL ENDOSCOPY. 
 
 position ancl has been but sHghtl\- improxed upon. As it seems to have 
 been forgotten, an illustration of it taken from an old instrument cata- 
 logue is here reproduced (Fig. (iS). 
 
 Alouret (Eiib. -lUU ) arrives at the necessary forward position of the 
 head by having the patient sit astride of a narrow backed chair facing 
 backwards with the pelvis as far toward tiie front edge of the chair as 
 possible, the pehis being tilted forward toward the operator who is back 
 of the chair as will be seen by referring to Fig. (i!i. 
 
 The author's position for direct laryngoscopy upon the sitting patient 
 under local anesthesia will Ije understood by reference to Fig. 70. This 
 position is also u.sed occasionally for diagnostic bronchoscopies, never 
 for esophagoscopies. 
 
 Fig. 68. Kirstein poMtiuii hIikIi cmuains the essentials of the best position for 
 direct laryngoscopy on the sitting patient. The extreme anterior displacement of 
 the cervical spine with extension only at the occipito-atloid joint and avoidance of 
 instrumental counterpressure on the upper teeth are fundamental. This illustration 
 is reproduced from an old instrument catalogue. (1895) Bib. 323. 
 
 The patient should be seated on a stool about :')ii cm. high. The 
 operator sits upon a stool rather lower than shown in the illustration. 
 The second assistant sits on a high stool back of the patient keeping the 
 patient's head far forward toward the operator, extended or flexed as 
 desired, usually extended as shown, but always forward. The assistant's 
 knee at the back of the ])atient prevents the ])atient moving liackward, 
 and. most imjiortant. ])revents the patient arching his spine backward. 
 This assistant's right index-finger is used when necessary for making 
 counterpressure externally by pulling the thyroid cartilage backward. 
 The operator's knee against the patient's knee holds back the patient's 
 hips. In exposing the larynx by direct laryngoscopy it is absolurcl_\-
 
 POSITION 01* THE PATir.XT I"OR PERORAL ENDOSCOPY. 
 
 83 
 
 essential for prompt work and especially for prompt recognition of 
 landmarks that the head he held exactly in the anteroposterior vertical 
 plane. In other words, neither the cervical spine nor the head should 
 he permitted to rotate. The head may be in any position desired as to 
 fle.xion or extension, but the fundamental instruction to the assistant who 
 holds the head should be: "Prevent rotation of the head."' 
 
 Fig. Cx). Position of Mourct. This lias llic :irI\aiitaKc tliat tlic patient's body 
 cannot slide forward toward tlic operator wlicn the head is pulled forward. Prof. 
 Mourct demonstrated that the position of the pelvis and dorsal spine arc important. 
 
 Keciimhci'i f>ositwn for direct laryntioxcopy, hroiiclioscof'y and csof>li- 
 agoscopy in adult patients. For the last eight years the author has 
 used the IJoyce position for bronchoscopv and esophagosco])y and has 
 found it to fulfill e\ery reijuirement. In the few adult ])atients rec|uiring 
 general anesthesia for direct laryngoscopv it is also used. .\ full de- 
 scription written h\ I)r. i'.iiyce is given in the earlier \iilunic. ( llih. 'i*>'K 
 1007.) Essentially the ])osition (Fig. 72) consists in having the pa- 
 tient's head and ujjper jiart of his shoulders out in the air supjinrtcd by
 
 84 
 
 POSITION OF THE PATIENT FOR PERORAL ENDOSCOPY. 
 
 the second assistant's left hand, which in turn is supported on the as- 
 sistant's left knee, the left foot being upon a stool whose top is about (52 
 cm. below the top of the table. All the extension and raising of the pa- 
 tient's head is done with the left hand of the assistant whose thumb is 
 on the patient's forehead, the fingers being under the occiput. The mo- 
 tion is as if to tnclc the forehead back, down and under, while at the 
 
 Fig. 70. Showing; the author's position of the operator, patient and assistant 
 for direct laryngoscopy on adult patients under local anesthesia. The sitting posi- 
 tion of the operator renders laryngeal exposure easy for patient and operator; 
 whereas the usual standing position of the operator throws the patient into a pos- 
 ture that renders laryngeal exposure difficult hesides throwing the trachea out of 
 line The author prefers a lower stool as shown in Fig. 77. 
 
 same time the neck, chin and whole head arc raised. The right hand 
 is passed under to the far side (left) of the patient's mouth, the right 
 index carrying the bite block. The right arm, however, usually car- 
 ries but little weight, most of the extension and the very important 
 prevention of rotation being done by the left hand. If the operator and 
 assistant work together frequently they can do bronchoscopies without
 
 POSITION 01' THE PATIENT FOR Pl'.RORAE ENDOSCOPY. 
 
 85 
 
 loss of time and with a precision tliat cannot lie cc|iialle<l by an\- other 
 mcliiod. Tliis position has nothing to do with the kind of instrument 
 used. There is no instrument made for bronchoscoiiy or esophagoscopy 
 that will do away with the necessity for a correct [losition of the patient 
 t(jr liest results in <|uickness and precision. With the patient recumbent 
 on an operating table of the ordinary height the direct laryngoscopist 
 should sit on a stool such as the anesthetist uses. For bronchosco])y 
 (recumbent position), especially after the bronchoscope has been in- 
 troduced, a lower stool is often re(|uired unless the posterior branches 
 are being explored. For the middle lobe bronchus it is necessary for the 
 operator to sit on a footstool. In beginning an esophagoscopy the 
 operator stands. Later he sits on a low stool for the lower third of 
 
 Fig. 71. Child with liiuli ihirs;il liilicrculosis at llu- I'itlsljiiruh 1 ln-,|iit;il for 
 Children. The author maile a direct laryiinoscoiiic examination, without changing 
 tlie child's position or removing the apparatus, by standing' on the left side of the 
 bed. as demonstrated by Richard H. Johnston, Fig. 11. This child had a flabby up- 
 per laryn.ycal orifice causing an inspiratory stridor. 
 
 the esophagus. The neces.sity for stools of different heights for the 
 operator is lessened in special tables l)y the elevation or lowering of 
 the entire table, patient and all. by sjiecial mechanism. The raising and 
 lowering of the head and tlie lateral movements will be considered wlien 
 writing of the introduction of the instruments and of \ariiuis i)rocediues. 
 Moslier ( Hill. .'IHO 1 demonstralcd ilie \aluc of tlexion of the head m 
 the recumbent i)ositi(jn for direct laryngoscopy by a laterally rotating 
 speculum. Richard H. Johnston (liib. •iSC ) demonstrated the usefidness 
 of flcxiufi the head in certain cases for direct laryngoscopy on the re- 
 cumbent patient, j/utting a small pillow under the ])atients' head, the 
 ni)erator standing to the left side of the jiatient. This flexed position 
 is particularly advantageous where the operator is without a regularly
 
 8G 
 
 POSITION OF THE PATIENT FOR PERORAL ENDOSCOPY. 
 
 trained assistant with whom he is in the habit of working, because any- 
 one can hold the head on the pillow. The position is not adapted to 
 bronchoscopy, though Johnston uses it to start the tube, and then the 
 head of the patient is brought into the Boyce position. This change re- 
 quires a well-trained assistant and great care to prevent any traumatism 
 to the trachea in making the change. I have found the Johnston posi- 
 tion exceedingly useful in disease of the cervical spine where the chil- 
 dren were fixed in an apparatus which I did not need to disturb to get 
 an excellent view of the larynx (Fig. 71). 
 
 Fig. "/i. Position of patient and second assistant in bronclioscoiiy and esopli- 
 agoscopy (Boyce position). Tlie left hand is supported on the left knee, the 
 left foot being elevated on a stool. The right forearm is under the patient's neck, 
 the right index carrying the bite block. Tlie right forearm carries little weight, 
 most of the e-^;tcnsion being done with the left hand. 
 
 Position of tlic patient. Children. Children are always best ex- 
 amined in the recumbent position, and there being no anesthetic, general 
 or local, it is usually rec|uired that they be held. The method of doing 
 this is as follows : The child is placed in the correct position on the 
 table with reference to the end of the table so that the head will be out 
 in the air for the second assistant to hold. P.nth knees are held down 
 by a nurse who stands at the foot of the tabic. Both hands are held 
 down, one at each side of the [latient either by a nurse or by a physician
 
 POSITION OF THE PATIKNT FOR PERORAI, ENDOSCOPY. 
 
 87 
 
 who is watching the puke. Tliis same person can also prevent the cliild 
 from throwing the chest upward, as some children do. I'pward move- 
 ment of the chest is to be avoided because it has relatively the same 
 effect as depressing the iiead. The position of each of the three persons 
 required will be understood by reference to Fig. 7;>. 
 
 This holding is only required with a terrified child es])ecially the 
 first few times. Most children soon lose all fear and where necessarv 
 
 Fifj, 73. Position of patient, assistant and two nurses to hold a child for di- 
 rect laryngoscopy, bronchoscopy and esophagoscopy. The assistant holds the head 
 in the Boyce position. The nurse on the patient's right holds the patient's wrists 
 down on the table. The nurse on the left side of the patient holds down the pa- 
 tient's knees. The operator is holding the direct laryngoscope. As soon as it is 
 introduced the patient's head is raised al)ove the level of the table. 
 
 to have repealed endoscopies they soon learn that the procedure is not 
 painful and submit without being held. 
 
 The author often has children of '■> and 1 years lie down on the 
 table, open their mouths and wait for a speculum to be inserted and 
 papillomata removed, time after time, without any holding whatever ex- 
 cept the supjiort of the head iiy the second assistant. 
 
 As in the sitting position of the patient, or.e of the most inipuriant 
 things is strongly to im|)ress upon the mind of the assistant who holds 
 the head that nc\er, under any circumstances is he tn iiermit the head tn
 
 88 
 
 POSITION' OF THE PATIENT FOR PERORAL ENDOSCOPY. 
 
 rotate. Tlie head must yield freely and follow the operator in the 
 lateral or vertical plane, but it must never rotate on the axial bone or 
 the cervical spine. Such rotation distorts the endo-anatomical land- 
 marks and renders difficult the otherwise easy task of tinding the larynx 
 or ])yriform sinuses, as the case may be. 
 
 '"'U 7.3 \- -Author's position of the patient for tlie removal of foreign hodies 
 from the larynx or from any of the upper air or food passages. If dislodged, the 
 intnidir will not he aided by gravity to reacli a deeper lodgement. 
 
 For the use of the esophageal speculum the patient may be placed 
 cither in the sitting position as for laryngoscopy (Fig. 70), or in the 
 recumbent positinn as for starting the introduction of the esoi)hagoscope 
 f Fig. ";'■>). The author prefers the latter.
 
 CHAPTER VII. 
 
 Direct Laryngoscopy. 
 
 General considerations. Enthusiastic as he is in regard to the use- 
 fulness of the direct method, for both diagnosis and treatment, the au- 
 thor wishes to state at the outset that he examines every case by the 
 indirect method first, if it is possible to make such an examination. The 
 exceptions arc in infants and small children who cannot be examined by 
 the mirror imless they are under a general anesthetic, and also an occa- 
 sional case of great nrgcncy in adults. The field of llic two methods is 
 entirely different. The presence of the tube excites reflexes which inter- 
 fere with the detection of slight \ariations in mobility, unless anesthesia 
 is profouiKJ, and then onlv resi)iratorv movements could he ])ri.-scnl. 
 Of course, great facility enables one to overcome this drawback to some 
 extent and also the disadvantage which comes from the increased ten- 
 dency to distortion, owing to very slight lateral displacement of the tube 
 or the tissues. Xe\ertheless it may be stated as a general rule that the 
 direct method is not adapted to accurate determination of motile detects. 
 One great advantage of the use of both methods in the same case, where- 
 cver ])ossible, is that the view-point is entirely different, the one supple- 
 menting the other. The view obtained in the mirror, ]\1, Fig. 7-i, is as if 
 the observer's eye were at the vertex of the patient's head, represented 
 by A In contrast to this, in the direct examination, the observer's eye 
 is at D. W ere the tissues to be examined a plane horizontal surface, there 
 would be practically no difference, but in examining a more or less funnel- 
 shaped cavity, like the larynx, the difference of the point of view become? 
 verv great, especially as to the position of growths down within the funnei 
 (as for instance at the cord) in their relation to the uiijar l.nyngeal orifice. 
 It will be easily understood from the schema. Fig. 71, that growths on 
 the cords always give the appearance of Ijeing located nearer the pos- 
 terior commissure than they actually are, and very much nearer than 
 thev seem to be b\' the direct method. Another great difTercncc is that
 
 !)0 
 
 dirf.ct laryngoscopy. 
 
 the direct method gives a better view of the anterior aspect of the pos- 
 terior wall, H, of the larynx because the visual axis is more nearly per- 
 pendicular to the surface. The indirect view of the posterior surface of 
 the posterior wall can, of course, be very much increased by von Eicken's 
 method of drawing the larynx forward so as to see the hypopharynx by 
 
 D 
 
 A 
 
 Fig. 74. — Schema illustrating the difference between the views obtained by 
 direct and by indirect laryngoscopy. The observer's visual axis at E, looking 
 into the mirror, M, pets an image as if he were looking from a point back of the 
 patient's head, .\. Looking thus, the image of a growth on the cord at C is 
 seen just over the top of the arytenoid eminence to which it seetns very close, 
 because almost in line. This schema also shows how the anterior surface of the 
 po-Sterior wall at H, is in the line of vision by direct laryngoscopy and more or 
 less hidden in some cases during indirect examination, by an apparent forward 
 overhan.g of ihc liorder of the arytenoid eminence and the aryepiglottic fold. 
 
 hypopharyngoscopy. The hypopharynx can also be viewed by putting 
 the direct laryngoscope down back of the posterior wall at H, and draw- 
 ing the entire larvnx forward. It is also worthy of note that the an- 
 terior surface of the posterior wall can often be observed l>y the Killian 
 method of using the laryngeal mirror with the i)atient standing and the
 
 DIRIXT LARYNGOSCOPY. 91 
 
 observer kneeling, the patients' head being bent forward and downward 
 toward the observer. 
 
 It may seem strange at this late day for anyone to advocate the 
 more frequent use of the indirect, mirror larj'ngoscopy, and yet it is 
 neglected in routine surgical work. The author believes that general 
 anesthesia for any purpose should always be preceded by a preliminary 
 examination of the laryn.x by the indirect method, provided the patient 
 can be so examined ; and this statement applies to any and all cases, sur- 
 gical or otherwise, for which an anesthetic is desired to be given. It is 
 incomprehensible why it is so generally neglected before goitre opera- 
 tions. If this rule were observed, there would not be as many myster- 
 ious deaths on the table and shortly after operation to be accounted for 
 by such highly hxpothetical diagnoses as hyperthymization, cardiac 
 failure, etc. The author knows of a number of deaths on the table 
 where paralysis of the larynx had existed unknown to the surgeon ; and 
 a perusal of surgical literature reveals cases strongly suggestive of un- 
 suspected laryngeal paralysis. 
 
 When it comes to operations, however, the indirect method has no 
 place in the author's technic. In making this statement, the author 
 wishes to qualify it by saying that he does not pretend to have the fa- 
 cility in indirect operating that is possessed liy man\- of the laryngolo- 
 gists, who. by a lifetime of training, have acc|uiretl wonderful skill in 
 working by the aid of the reversed image seen in the mirror. The skill 
 of such men as Delavan, Semon, St. Clair 'J'homson, liryan, rrench, Cur- 
 tis, McKernon, Simpson, Tilley, Dundas Grant. Moritz Schmidt and 
 others in overcoming tlie disadvantage of being compelled to move a 
 forceps backward when it is desired to bring it forward, and to make 
 a diagonal movement by combining a reversed antero-posterior and a 
 true lateral movement, is marvelous and probablv will not be e(|ualled 
 b\' any future generation of laryngologists because there is not now the 
 incentive to spend the lifetime at practice necessary to acquire the skill 
 to work under the peculiar circumstances of having the antero-i)osterior 
 movement reversed while the lateral movements are unchanged. This 
 must not be taken, however, to mean that good work can be done by the 
 direct method without a large amount of jiractice, nor that a superlative 
 degree of skill cannot be acquired in the direct method. The same amount 
 of work will produce equally marvelous results with the direct method 
 as were accomplished by the indirect, and the results will be vastlv great- 
 er because of the greater possibilities of the direct procedure. 
 
 \'ery young children, because of their being intractable and terri- 
 fied, are difficult cases for the mirror-method of indirect lar\ngoscopy, 
 but in addition, as shown by Swain ( Hib. oOS), the epiglottis adds great-
 
 92 DIRECT LARYNGOSCOPY. 
 
 ly to tlie difficulty as compared to the adult epiglottis. Moreover, the 
 child's epiglottis is prone to curl. In the direct method, on the other 
 hand, we have a method by which the larynx of any infant or older 
 child can be examined without any anesthesia, general or local. The 
 erroneous statement that anesthesia is required has crept into the litera- 
 ture, and has prevented the widest use of direct laryngoscopy for the 
 diagnosis of the various causes of croupy cough in children too young 
 for mirror inspection. Nearly all cases of papilloma and of unsuspected 
 foreign body in the larynx have had diphtheria antitoxin given because 
 it was supposed that the larynx could not be examined v\-ithout anes- 
 thesia. Worse still, are the deaths from attempts to administer an alto- 
 gether unnecessary general anesthetic to a child w-ith a stenosed larynx. 
 
 In dyspneic cases, the possibility of retropharyngeal abscess must 
 be borne in mind, and the posterior pharyngeal wall should always be 
 carefully inspected before bronchoscopy. Of course, this can be done 
 with the lingers by palpation, Iiut ihe most ready way is just habitually to 
 note the condition of the posterior pharyngeal wall when introducing the 
 direct laryngoscope. 
 
 Contraindications to direct laryngoscopy. The author can recall no 
 absolute contranidications to direct laryngoscopy in any cases where di- 
 rect laryngoscopy is really needed for either diagnosis or treatment. In 
 extremely dyspneic cases if the operator is not prompt and certain in his 
 introduction of a bronchoscope it may be wise to do a tracheotomy first. 
 
 The direct laryngoscopic appearances. The illustrations in this book 
 may seem a little queer to those accustomed to the old indirect illustra- 
 tion. The \iews in the sitting patient seem "upside down." Yet simply 
 to re\erse an indirect view will not give a direct picture because the view 
 point is different as already explained. The epiglottis does not show be- 
 cause it is hidden by the direct laryngoscope. If the glottis is wideh 
 open, the observer looks directly into the trachea in the direction of 
 its long axis; and therefore does not see one tracheal wall any more 
 than the other, if the head and neck of the patient are placed in the 
 proper position. All the indirect illustrations represent the rings of the 
 trachea showing below the glottis. If the patient gets his head too far 
 backward (in the sitting position), the anterior wall may possibly be 
 thus seen, because in such a position the observer's eye is back of the 
 larynx and is in almost the same position with reference to the larynx 
 as is the mirror in indirect laryngoscopy. This will be understood by 
 referring to Fig. 74. But this is a very wrong position for direct laryn- 
 goscopy, as elsewhere herein explained. When the patient is in the posi- 
 tion shown in Fig. 70. the posterior wall of the trachea is more easilv 
 seen tlian the anterior, though if the position is exactlv correct, neither
 
 DIRKCT LARYXGOSCOPV. 93 
 
 will be more conspicuous tlian the other, because the operator will be 
 looking directly down in the tracheal axis. If the posterior wall is 
 viewed, no rings will show because the posterior wall of the trachea 
 is devoid of cartilage below the cricoid. 
 
 Illustrations of the laryngeal image on mirror view have always 
 been misleading. They are semidiagrammatic and lack depth. This is 
 one of the things that contributes most to the disappointment of the be- 
 ginner in direct larAiigoscoiJy. He never knew that the vocal cords were 
 so deep. They are. in the adult, nearly :! cm. below the aryepiglottic 
 folds, and not almost on a level with them as illustrations of indirect 
 views have usuallv pictured them. \\'hen the beginner in endoscopy 
 examines them directly, and still more when he first attempts to operate 
 upon them, they seem almost hopelessly far away ; and to make matters 
 worse they are quite likely to be obscured from time to time by spas- 
 modic narrowings of the lumen by the false bands and even by the up- 
 per orilice of the larynx posteriorly. The illustration. Fig, !•, Plate 1, 
 gives some idea of the depth of the larynx because the hand stretches 
 across near the level of the lop of the false bands. The reasons for the 
 misconceptions as to the real depth of the cords are four: 1. Illustra- 
 tions of the larynx are made from memory and are always more or less 
 diagrammatic, i. The cords are the central point of interest and are 
 unconsciously always strongly represented in the illustrations with a 
 glistening whiteness that brings them right up to the nearest plane in the 
 laryngoscopic picture. ;!, Text-book tradition has called them white 
 so that white they are painted, it matters not whether they are ^ray, 
 l^early, dark greenish gray, bituminous, yellowish pink, bluish pink, 
 bright pink, or tinged by reflected light. The artist giving them their 
 true color value would make them stand back at their true depth. But 
 it takes a lifetime to train the artist's eye to see values, and it takes an- 
 other lifetime to train the laryngologist to see laryngcs, Conse- 
 quentl\- there are no artist-laryngologists, \. There is, owing to well-known 
 o])tical laws, an actual foreshortening of the laryngeal image as seen in 
 the laryngeal mirror. If anyone doubts the author's statement that the 
 cords are rarely reallv white, let the doubter compare the whiteness of 
 some cases of painlloma or of the while, grass-like projections sometimes 
 seen in certain cases of malignancy, A good demonstration of the fore- 
 shortening affect of the mirror is apparent in comparing the flat ribbon- 
 like appearance of the cords, with their actual a[)pearance. This ribbon- 
 like appearance is not so much in evidence with the direct method, and 
 when the larynx is opened by ihyrolomy it is seen to have been an illu- 
 sion. (See Figs, SI and -ISS).
 
 91 DIRKCT LARYNGOSCOPY. 
 
 Ill Studying the direct laryngoscopic image it must be remembered 
 that tlie lary-nx, like the face, is full of muscles and is changing its ex- 
 pression every moment. The laryngologist who sketches as accurately as 
 he can will notice that no two sketches are exactly alike. The author 
 has been criticised, by students who did not understand this, for repre- 
 senting the same epiglottis or the same larynx differently at different 
 times. It is only under the most profound anesthesia with abolition of 
 all except the deep reflexes that wc see the glottic chink enlarge and 
 diminish in perfect rhythm with the respiratory movement without ac- 
 ccssor\- movements in any part. And even then symmetrv may be in- 
 terfered with by distortive instrumental traction. Without anesthesia 
 there is usually more or less spasmodic traction of the arytenoids, and 
 the ventricular bands are \ery apt to close o\er the cords and to narrow 
 
 Fk;. 75. — Direct laryngoscopic views local, partial or no anesthesia. A, epi- 
 glottis. (It is often more curled than this.) First stage of direct laryngeal ex- 
 posure. B, laryn.x exposed but orifice is narrowed by spasm. C, a moment later 
 when orifice widens and .i;lottis opens on deep inspiration. D, posterior part of 
 larynx as usually seen at beginning of third stage. This is more frequently seen 
 than B. If the larynx should open it would be seen that a much larger portion 
 of the glottis is visible than anticipated. 
 
 the upper laryngeal orifice, so that no cords are visilile. This jiertains. 
 to some extent, even under quite perfect local anesthesia. The picture 
 is very apt to be as shown at D in Fig. 7~>. consisting of two rounded 
 masses posteriorally with more or less showing of the rounded masses 
 anteriorally, corresponding to the \entricular bands. If, however, the 
 ])atient is commanded to keep on breathing and not to hold his breath, 
 the lirst deep inspiration will open up the glottis and then the view 
 should be as at C in Fig. 7."), except that it is not often that the begin- 
 ner will be able to expose the anterior commissure as there shown. 
 
 The field of vision at any particular moment appears much larger 
 than the diameter of the tube, and the author has so drawn and painted 
 it in the illustrations. The field actually is larger, the degree being de- 
 pendent upon the distance of the obiect viewed from the distal end of the
 
 DIRKCT T.ARYXC.OSCOPV. d'i 
 
 tul)c moulli as will he understood by reference to Fig. TG; but this fac- 
 tor, of course, in a long tube of small lumen, is ver}' slight unless the 
 object be very far from the distal tube-mouth. What contributes more 
 to the apparently larger size of the field as compared to the tubal diameter 
 is the general law of optics which explains why the farther away an 
 object is from the eye, the smaller the image, and consequently the 
 greater the area visible. Perspective contributes also the additional fact 
 that the nearer the plane of a receding surface approaches the visual 
 axis the greater the foreshortening, and the greater the foreshortening 
 the greater the area visible. In plain language the nearer a surface ap- 
 proaches to being seen on edge, the greater the area visible through an 
 aperture of a certain size placed at a certain distance from the eye. 
 Hence, in endoscopically \iewed surfaces close against the tube-mouth, 
 and vertical to the axis of the tube, we see an area equivalent to that of 
 the lumen of tin- tube niDUtli. whereas in \iewing surfaces receding in 
 
 C 
 
 B 
 
 Fjg. 76, — Schema .sliouiiv^ one of the reasons why the endoscopic image always 
 seems larger than the actual diameter of the tube tlirough which it is seen. This 
 is most apparent with the direct laryngoscope. The field of vision is larger in pro- 
 portion as the distance between the tube-month, A P., and the farther limit of the 
 visible field, C D. increases. 
 
 planes more or less approaching parallelism with the tubal axis we see 
 areas ec|uivalent to many times the area of tubal aperture. 
 
 Inslntctions to patients. I'.efore beginning endoscopy the patient 
 should be told that he will feel a very disagreeable pressure on his neck 
 and that he mav feel as if he were about to choke, and that he cannot 
 get his breath, lie must be gently biU lirmly made to unilersland: 1 1 ) that 
 while the procedure is alanning that it is absolutely free from danger: 
 (2) and that you know just how it feels; (;i) and that you will not al- 
 low his brealli In lie sluil oil completely; 1 I 1 ibal be can help you \er\' 
 greatly as well as make the ])rocedure very much easier for himself by 
 paying close attention tn breathing very dee])ly and regularly, in anil 
 out; (.5) lli;U he must not diaw himself up rigidU as if he were "walking 
 on ice," but must be easy and relax. It will contribute very much to 
 this end if the operator will be particularly gentle and careful about the 
 earlv manipulations of applying the local anesthetic and the like; and
 
 96 DIRIXT LARVNCOSCOPV. 
 
 \vi11 tell tlio pntie-nt. after the epiglottis is exposed ami tlie application of 
 the local anesthetic made to it. that there will be nothing worse to be 
 gone through with. Some endoscopists advocate telling the patient to put 
 up his hand if the procedure is too severe. The author prefers not to 
 do this because it leads the patient to think that he is about to go through 
 a severe ordeal which he may not be able to survive, and that he must 
 give notice of impending death. Moreover, he is apt to raise his hand 
 and grasp the instrument or the operator's hand. It is better to have 
 the patient's hands held down by a nurse. However, each operator will 
 develop his own method of controlling the patient and the author does 
 not care to urge his own method too strongly. A suggestion of Mr. 
 \\"aggette (Bib. 5GT) is particularly good: Namely that a special signal 
 be arranged by which the patient may inform the operator that the lips or 
 teeth are being painfully pressed upon. The operator interested in his 
 deeper work may otherwise overlook this little detail which is often, 
 needlessly the painful part of the procedure. 
 
 Technic of exposure of the larynx in tlic sittiiu/ patient. Exposing 
 the lar\ nx with the speculum in the sitting position should be approached 
 from the standpoint of depressing the tongue to find the epiglottis and 
 then depressing and drawing forward the epiglottis, tongue and all tis- 
 sues attached to the hyoid bone. By keeping this constantly in mind, 
 two of the greatest difficulties and errors will be prevented; namely, (1) 
 the tendency on the part of the patient to throw his head far back as if 
 he were about to have his neck shaved, and (3) the tendencv on the 
 part of the operator to follow the patient and thus to get his elbow high- 
 er and higher, his own head farther back and to use the patient's upper 
 teeth as a fulcrum in an effort to pry open the larynx, a movement that 
 defeats its own object. To avoid this, the author sits on a stool in front 
 of the patient precisely as if he were about to use a tongue depressor 
 to examine the pharynx. The position of the operator shown in Fig. 
 70 is the highest that should be attained at the complete exposure of 
 the larynx when the operator is looking directly into the trachea. In 
 beginning to introduce the laryngoscope the operator should stoop much 
 lower, having his head about level with iliat of the patient. (Fig. 77). 
 The introduction of the instrument should be considered in three stages. 
 
 1. Exposure and identification of the epiglottis. 
 
 2. Placing the spatular tip back of the epiglottis. 
 
 3. Anterior downward traction on the epiglottis and all the tis- 
 sues attached to the hyoid bone. 
 
 First stage. The patient's head being covered with a sterile cap, 
 the second assistant pushes llie patient's head and neck forward as shown 
 in Fig. 70. The operator holds the laryngoscope in his left hand (Fig.
 
 DIRliCT LARYNGOSCOPY. 
 
 97 
 
 Fig. 77. — ']"lic upper illustratinii vli,,w^ tlif tii>l ^taLji' dI" iliruii lar\ iignscop.v. 
 The operator is insertint^; the laryngoscope with his left hand while he holds the 
 patient's upper lip out of the way with the right inde.\ finger. In order to show 
 the instrument and the operator's hands the operator is standing to one side of 
 the patient. In actual work the operator sits squarely in front of the patient as 
 shown in the lower illustration.
 
 98 
 
 DIRECT LARYNGOSCOPY. 
 
 77) while with his right index he raises the patient's upper Hp so that 
 it cannot be pinched between the laryngoscope and the teeth. The distal 
 end of the laryngoscope is passed backward over the median line of the 
 dorsum of the tongue, and. depressing the tongue, in the direction of the 
 
 
 .^av 
 
 
 
 
 ^ "^^ 
 
 Fig. 78. — Schema showing the first and third stages in e.xposing the laryn.x in 
 direct laryngoscopy. At the left the tongue is being depressed as indicated by the 
 dart, causing the epiglottis to project into the line of vision as shown in the lower 
 illustration. Then the laryngoscope is inserted deeper constituting the second stage. 
 At the right is shown the third stage, the drawing forward of the epiglottis and all 
 of the tissues attached to the hyoid bone with the tip of spatular end, thus exposing 
 the spasmodically closed larynx as shown in the lower right hand illustration. At 
 the next inspiration the larynx will open, exposing the cords and glottis as shown 
 in Fig. 75. (See Fig. 70 for photograph of the positions at the third stage.) 
 
 dart in the left half of Fig. 78, the upper edge of the epiglottis will come 
 into view, as shown in the circle. The tongtie is depressed until the 
 epiglottis stands up rather prominently like the spout of a pitcher, and 
 shows a goodly portion of its anterior surface. Absolutely no effort 
 should be made to see the larynx until the first stage is accomplished.
 
 DIRICCT LARYNGOSCOPY. 99 
 
 namely, the identification of the epiglottis. If it fail to come into view, it 
 must he searched for a little more to the right or to the left; hut deep 
 insertion must he strictly avoided. Failure to find the epiglottis nearly 
 always means too deep insertion ; hecause, if the first step is properly 
 taken, namely, to depress the dorsum of th.e tongue slightly until the 
 epiglottis comes up into view, and if the speculum is exactly in the 
 median line, the epiglottis will promptly project upward right in the line 
 of vision, with the lingual surface of the epiglottis toward the operator, 
 as shown in A, Fig. 75, and in the left hand circle in Fig. 78. 
 
 Second stage. Having identified the epiglottis in the manner just 
 described, the next step is to pass the spatular end of the speculum pos- 
 teriorally to the epiglottis for a distance of about 1 cm. or l..j cm. 
 (slightly less than 1 cm. in a child). The depth of insertion cannot be 
 gauged by arbitrary measurements. Nothing but experience will enable 
 the operator to get it exactly right for the particular case, since the ne- 
 cessary distance is subject to wide individual variations. If the depth is 
 not correctly gauged the error will be revealed in the third stage. 
 
 Third static Witiiout permitting the laryngoscope to go deeper, 
 the larynx is exjic^sed by a movement of the spatular end of the laryn- 
 goscope in the direction of the dart in the right half of Fig. 78. This 
 movement is fundamental in c\])osure of the larynx. It is, perhaps, best 
 described as an eft'ort to pull the epiglottis and hyoid bone downward, 
 outward and forward toward the oi)erator with the tip of the spatular 
 end. The patient's whole head i^hould be inilled forward by the power 
 exerted. If this is kept in mind there will be no danger of falling into 
 the error of trying to pry open the larynx using the upper teeth as a 
 fulcrum. If the operator expects now to see the larynx as in the laryn- 
 geal mirror, lie will, in most instances, be disappointed for reasons al- 
 ready given. Usually a spasm of the larynx hides the cords from view 
 and all that is seen is the two rounded eminences over the arytenoids. 
 The jjatient must be encouraged and jiacificd if alarmed, and must be 
 frequently admonished to breathe deeply. .\l the first inspiration the 
 cords will be seen more or less hidden by the overhanging ventricular 
 bands, if the laryngoscope is properly ])laced and the effort of the oper- 
 ator's left hand is properly exerted. It re(|uires considerable strength 
 and endurance in the wrist to hold oul (jf the way the tissues of a mus- 
 cular ])atient with a shoii thick neck. If tlu- cords are seen, then it is 
 known that the laryngoscope is properly placed and that no harm can 
 Ije done by firm ])ulling in the proper direction, provided the instrument 
 is in the middle line. If in executing the third ^t.•Lge the epiglottis slips 
 away downward, the insertion of the second stage has not been deep 
 enough, and the ejiiglottis must be very carefully identilied again and the
 
 100 DIRItCT I.ARVXC.OSCOPV. 
 
 insertion made slightly deeper. If a hasty movement is made to catch 
 the epiglottis the aryepiglottic fold may be mistaken for the epiglottis 
 and then forward traction will expose the corresponding pyriform sinus; 
 which is bewildering to tlie beginner who concludes that the larynx is 
 hard to find. If. on the other liand, in executing the second stage the 
 laryngoscope is inserted too deeply, the hypo-pharynx will be entered and 
 the third stage will fail to expose the larynx and very strong muscular 
 effort will result in exposing the pyriform sinuses or even the mouth of 
 the esophagus. 
 
 Difficulties. If careful attention has been given to all the instruc- 
 tions as to position of patient and operator and to the successive execu- 
 tion of each of the three stages, there should be no great difficulty in suc- 
 ceeding in an average case after a few trials. But it is by no means easy 
 to execute every detail correctly, especially without a trained assistant. If 
 the head of the patient has l)een allowed to rotate or to deviate laterally, 
 the larv'Hx will not seem to be where it ought to be — in the median line. 
 If the laryngoscope has not been held firmly in the middle line, the same 
 "lost larynx" may result from the distortion due to the slipping sidewise 
 of the tongue and its attachments. If the laryngeal aperture cannot be 
 found the patient should be allowed a moment's rest during which he can 
 expectorate secretions. Each time the instrument is removed it should be 
 wi]jed clean with a square of gauze, because a patient does not like even 
 his own saliva put back in his mouth. The same movement wipes the 
 lamp. Then a fresh start should be made. If the larynx still fails to be re- 
 vealed the endoscopist should ask himself which of the hereinafter given 
 "rules" he has violated. If the larj'nx is correctly exposed squarely 
 before the Iar\-ngoscope, but only the posterior commissure is visible 
 even on deep inspiration, the pulling with the tip of the spatular end 
 should be increased and the patient's head should be brought further 
 forward toward the operator, and extension lessened rather than in- 
 creased. If the anterior commissure still fails to appear the second as- 
 sistant who holds the head should, with his right index linger externally 
 on the neck, pull the thyroid cartilage backward. If properly done, this 
 will expose the anterior commissure in any case, and this is often neces- 
 sary, in order to counteract the forward traction of the larynx by its at- 
 tachments to the hyoid bone. Like all purely manual procedures, practice 
 is required to render direct laryngoscopy easy and smooth in its execu- 
 tion, which is a matter entirely separate from knowiiicj hozv to do it. 
 
 Ria.Ks roR niKiiCT l.\ryxc.()scoi>y. 
 
 1. The laryngoscope must always be held in the left hand, never 
 in the right.
 
 DIRIXT LARYXGOSCOPV. 101 
 
 2. The operator's right index linger (never the left) should be 
 used to elevate the patient's upper lip so that there is no danger of 
 pinching the lip between the instrument and the teeth. 
 
 ■ K The patient's head must always be exactly in the middle line. 
 not rotated to the right or left nor bent over sidewise, and tbe ennre head 
 must be forward with extension at the occipito-atloid joint only. (Fig. 
 65). 
 
 ■1. The laryngoscope must always be passed over the dorsum of 
 the tongue exactly in the middle line (until the endoscopist is sutticiently 
 skilled to try the obli(|ue position \. 
 
 5. The ef)iglottis must always be identified before any attempt is 
 made to expose the larynx. 
 
 (J. \\"hen first inserting the laryngoscope to find the epiglottis, 
 great care should be taken not to insert too deeply lest the epiglottis be 
 overridden and thus hidden 
 
 7. After ideiititication of the epiglottis, too deep insertion of the 
 laryngoscope must be carefully avoided lest the spatula be inserted back 
 of the arytenoids into the hypo-pharynx. 
 
 S. E.xposure of the larynx is accomplished by pulling forward the 
 epiglottis and the tissues attached to the hyoid bone, and not by prying 
 these tissues forward with the upper teeth as a fulcrum. 
 
 !•. Care must be taken to avoid mistaking the ary-epiglottic fold 
 for the epiglottis itself. (Most likely to occur from rotation of the pa- 
 tient's head.) 
 
 lu. 'JMie tube should not be retained too long in place, but should 
 be removed and the patient permitted to swallow the accumulated saliva, 
 which, if the laryngoscope is too long in place, will trickle down into the 
 trachea and cause cough. ( Swallowing is almost impossible while the 
 laryngosco]ie is in position). 
 
 \\. The ])atienl must be instructed to breallu' dce])ly and i|uielly 
 without making a sound. 
 
 12. In the sitting position of the patient, the i>])erator should als(j 
 be sitting. 
 
 Direct laryiuioscopx by hitercil and oblique methods. In the fore- 
 going description of the technic of direct laryngoscopy, it is stated that 
 the instruments should be jiassed exactly in the middle line (i\er the 
 dorsum of the tongue. This is intended to render orientation easy. After 
 facility is acquired and the faculty of readily recognizing various land- 
 marks is developed, it will be found a great advantage in exposing the 
 larynx to pass the laryngoscope at the side of the tongue from the cor- 
 ner of the mouth, the head being turned very slightly toward the oppo- 
 site side. Otherwise the position is the same as by the regular method.
 
 102 DIRKCT LAKYNGOSCOPY. 
 
 As the exposure is obliciue, the larynx will look somewhat asymmetrical 
 and more will be seen of one wall than of the other. This, however, is 
 of very great advantage when it is desired to inspect the ventricle, the 
 laryngoscope being passed from the corner of the mouth opposite to the 
 ventricle to be examined ; that is, through the right corner of the mouth 
 when the left ventricle is to be examined, and vice versa. The oblique 
 method also is of very great ad\antage in the removal of tumors from 
 the ventricle and from the subglottic regions, and very often from the 
 cords themselves, the speculum being passed from the corner of the 
 mouth opposite to the side of the larynx on which it is intended to 
 operate. A narrow tube laryngoscope such as shown in Fig. 21 (child's 
 size ) is best adapted to larvngoscopy at the side of the tongue. The 
 author cannot understand Briinings' objections to the lateral route. 
 
 In using lateral opening specula such as the one shown in Fig. 15, 
 with the slide oiT. it is best to pass the instrument to one side of the 
 tongue, selecting the side that will leave the tongue on the side of the 
 instrument that has no opening. If the tongue is on the side of the 
 opening the tongue will crowd into the opening, and obstruct the view. 
 These lateral opening specula, however, are not especiall)- intended for 
 lateral use. They are useful only for regular dorso-lingual passage under 
 general anesthesia. They are too wide for use under local anesthesia. 
 
 Exposure of the larynx iintli the instruments of Briinings, or of 
 Kahler, and with all modifications of these and of the author's laryngo- 
 scope, is precisely the same as described in the foregoing. The technical 
 illustrations show the author's instrument but the movements are identi- 
 cal with all other instruments of the same position of handle, which has 
 come to be universallv employed for the sitting position. The simple 
 L-shaped laryngoscope has been generally abandoned for laryngoscopy 
 upon the sitting patient. The only difiference in the use of the various 
 laryngoscopes for this purpose is in the management of the illumination, 
 proximal, distal or headband types. Killian uses an improved form of 
 Kirstein headlamj) for all direct laryngoscopic procedures except for 
 demonstration, for which he uses the handlamp at the proximal end of 
 the tube. 
 
 Subglottic laryngoscopy. For examining the subglottic region in 
 adults the child's size of the esophageal speculum. Fig. 21, is very sat- 
 isfactory. It is used instead of the laryngoscope to expose the larynx, 
 and then it is gently slid down into the glottis while carefullv keeping in 
 view the two arytenoid eminences as the tip of the speculum enters the 
 glottis. In children, however, the author prefers to insert one of his 
 regular bronchoscopes. Fig. Ki, because the instrument is extremely 
 light and delicate, therefore there is no danger of causing subglottic
 
 DIRKCT LARYNGOSCOPY. 103 
 
 edema. The Briiiiings and Kahlcr bronchoscopes may be used for either 
 ackilts or children in the way jnst described for the child's esophageal 
 speculum. Great care should be used in thus examining the subglottic 
 region of children, for the reason given. 
 
 THE TKCIIMC Ol" IlIKKCT L.\RYNC.i:.\L OPKRATING. 
 
 The picl^amtioii of the patient, local as well as general, should be 
 carried out as elsewhere herein suggested. Particular attention should 
 be given to oral antisepsis, however trivial the growth and its removal 
 may seem to be ; and the general examination should never be omitted 
 except in great emergency. 
 
 Anesthesia has been elsewhere considered in detail. For direct 
 laryngoscopy upon the sitting adult patient it is usually local, never 
 general. The more thoroughly it is carried out the easier will l)e tlie 
 operation, because of the lessening of the reflex spasm, not because of 
 need of analgesia.* 
 
 Left-hand exposure. The prime essential of direct laryngeal oper- 
 ating is perfect mastery of continuous left-handed laryngeal exposure. 
 The left hand must be able, unaided, not only to expose the larynx but 
 to maintain the exposure for at least a minute. Many operative pro- 
 cedures can lie completed ni this time if a ])roper pl.in of working has 
 been devised. Those that ret[uire a longer period can be C(jmpleled by 
 removal and reinsertion of the laryngoscojie. The author personally 
 finds no difficulty in holding the larynx open for ten tn iifteen minutes 
 if need be, and Ur. Jillen J. Patterson has fre(|uently held the larynx 
 exposed for a twenty-tive minute radium a[)plication. Yet most oper- 
 ators lind prolonged exposure tiresome ; and there is no objection to in- 
 termittent exposure, with intervals for ex])ectoration, provided the e.x- 
 posure is steady and efficient with the left hand only. This is not at all 
 difficult to acquire if the student will begin right, as previously ex- 
 plained, and follow precisely the directions herein given for direct laryn- 
 geal exposure, always with the left hand only. Like all purely manual 
 procedures, especially bimanual procedures, such as the playing of mu- 
 sical instruments, what seems at first difficult becomes easy with prac- 
 tice to those who are not discouraged by early ditficultics. 
 
 Endoscopic use of laryngeal forceps. Having mastered direct 
 laryngeal left-hand exposure the next step is to learn the use of for- 
 
 •Tlie rellt'X .spa.im here refeiieil to is the oidinar.v Blottie mi)vement. The 
 statement of .some authors that the interior of the larynx shouid be cocainized to 
 prevent re.xpiratory arrest from "vaBTU.s rellexes" can only refer to patients under 
 ijrenerai nne.slhrsia. possil)l.v partially iindei". In over one lh<Jiisand dii-ect laryngeal 
 operations and bronehoscopiea l)y l>r. I'alter.Mon and the autiior tliere has never 
 been an arrest of respiration when no anesthetic, general or local, was used.
 
 104 DIRIX'T LAUVNGOSCOPV. 
 
 ceps. A multiplicity of forceps for the removal of growth is quite un- 
 necessary and is really a great hindrance to good work. It is far better 
 to rely upon one forceps such as that shown in Fig. 35, and by culti- 
 vating dexterity with this instrument all the different forms and posi- 
 tions of growths as shown in Fig. 7!' can be removed with far greater 
 precision than if all (littorcnt forms and angles of jaws, guillotines, etc., 
 are tried first and found wanting. \\'hen the one forceps is mastered, 
 others may be added as found desirable. It 5s the author's custom to 
 have the jaws always set to open the one way — up and down. If any 
 other angle may seem desirable, the forceps are tiu'ued in the hand even 
 to complete reversal, the thumb and finger exchanging rings. This may 
 not appeal to many, and the author would not urge it ; but he does espe- 
 
 FiG. 79. — Indirect views of different types of laryngeal growths. A. Multiple 
 papilloniata in a woman of 25 years, requiring traclieotomy. Cured by repeated 
 direct laryngoscopic operations. B. Multiple infra-glottic tibro-papillomata in a 
 woman of 54 years, cured Ijy direct operations. C. Fibroma attached to the 
 under surface of right cord at the anterior commissure in a man of 39 years. Cured 
 by a single removal. D. Subglottic angioma in a man of 42 years. All of these 
 different types of tumor were removed with the one form of tissue forceps (Fi,g. .55) 
 illustrating the Heedlessness of a large variety of forceps. 
 
 cially urge that all early practice work be done with the one forceps and 
 with the jaws opening only one way until the eye is trained to watch the 
 forceps open and close. 
 
 The gauging of depth by the use of one eye only is at all times 
 difficult except by prolonged practice. It is more than usually difficult 
 in direct laryngeal operating because of the misconception as to the 
 real depth of the larynx, as before mentioned. These two factors 
 contribute to such accidents as shown at B, in Fig. SO, where, in the 
 attempt to reach a growth of the cord, miscalculation as to the real depth 
 of the growth and of the cord from which it sprung caused the oper- 
 ator, who was a very skillful man by the indirect method, to punch out a 
 section of the ventricular band leaving the floor of the ventricle ex- 
 posed to view. While this is not a \crv grave accident, if not too far 
 posteriorly, it is one to lie a\()i(led on the general principle that all un-
 
 DIRECT I.ARYNC.OSCOPV. 105 
 
 necessary laryngeal trauma is always to be avoided with the utmost 
 care, because onlv by so doing can we hope for the highest percentage 
 of good results. Serious vocal impairment may result from such an ac- 
 cident if relatively deep down i)osteriorly. A still more serious acci- 
 dent is seen at C. where a large jjart of the left cord was afterward dis- 
 covered at indirect laryngoscopy to have been punched away leaving 
 the fibroma unharmed. Worse yet is the accident shown at D, where a 
 large part of the arytenoid cartilage has been removed and the arytenoid 
 mo\ements jiermanently imjiaired. As shown by the author the chief 
 factor in the jiroduction of an efficient adventitious vocal cord is the 
 traction of an unimpaired ar\tenoid. L'nfortunately misdirected excisions 
 are espccialh- liable to be located posteriori}'. Only by practice can the 
 
 Fig. 8o. — A direct view showing hiding of the end of the forceps by spasmodic 
 closure of the ventricular bands. At the same moment the upper orifice of the 
 larynx closes somewhat also, though this is not shown in order to illustrate the 
 spasmodic closure of the bands. The operator thinking his forceps correctly placed, 
 closes tlicni, and, later at inchrcct laryngoscopy, is surprised to find the ventricular 
 band cut away and the growth below unharmed, (B). A worse accident is sliown at 
 C where llie posterior half of the cord is removed leaving the fibroma unharmed. 
 Still more serious is the accident at D, where a large part of the left arytenoid was 
 removed. ( B, C, and D were sketched by the author from cases seen in mnsulta- 
 tion immediately after the accident.) 
 
 faculty of gauging tlepth be actiuircd. and especially by practice which 
 enables the operator to work with both eyes open, ignoring the image 
 of the left eye. A darkened room assists in acquiring this faculty. If 
 the habit of holding the left eye closed is formed, the vision of the right 
 eye is, for the tiine being, impaired and the operator is needlessly fa- 
 tigued, as pointed out by the author many years ago. Another factor 
 in the avoidance of the accidents above referred to is to make it a ruk' 
 to work only by sight. The jaws must be seen to close properly on the 
 growth, otherwise they nuist not be closed. In the event of a spasmodic 
 contraction of the laryn.x, gras]iing the forceps as shown at A. in Fig 
 SO, the forceps should be withdrawn and if working under a local anes- 
 thetic more nf the anesthetic solution should be ai)i)lied. If working un-
 
 106 DiRr:cT laryngoscopy. 
 
 (ler a general anesthetic, (recumbent patient) the depth of the anes- 
 thesia should be increased. If working without an anesthetic an oppor- 
 tunity must be awaited when the larynx is free from spasm. A child 
 will clean its throat by swallowing or the secretions will drain out if the 
 child is turned over. If the field is covered with blood or secretions, 
 rendering accurate guidance of the forceps impossible, the larjngoscope 
 and forceps must be removed and the patient told to "clear his throat.' 
 If a growth at the anterior commissure fails to come into view, the as- 
 sistant holding the head uses his inde.x finger to press backward the 
 thyroid cartilage, at the same time steadying it, and this counterpressure, 
 when properly exerted will bring into view the anterior commissure in 
 any case where the endoscopist is holding his speculum properly. Either 
 lateral wall above or below the commissure can be rendered prominent 
 by skilled counterpressure. Under no circumstances should the operator 
 attempt to reach a growth anteriorly that he cannot see, simply from his 
 memory of its location at previous indirect laryngoscopy. 
 
 In the removal of small tumors, either on the cords or below, it is 
 often a very great advantage to introduce the speculum and to work from 
 the opposite side; therefore, in rightsided tumors, the speculum is put in 
 the left side of the mouth and on the left side of the patient's tongue. 
 Then by moving the patient's head to the right, we get a good view of 
 the right wall of the larynx. In very sensitive adult patients, it may be 
 wise to make an application of 8 per cent cocaine solution along the side 
 of the tongue at the back, on the side through which the speculum is to 
 be passed. To those who try this method for the first time, there may 
 be some trouble with the tongue rolling over the open portion of the 
 speculum and obstructing the view, but the operator soon learns to con- 
 trol this. In tumors below a cord (as at D, Fig. 7!)j there is a great 
 temptation to use a sliding punch forceps, which, however, is almost cer- 
 tain to remove the cord and muscular tissue. A better method is to tilt 
 the cord over sidewise with the spatular end of the laryngoscope and the 
 growth thus can be presented fairly in front of the spatula by extreme 
 lateral movement, as shown in Fig. 80, and by pushing firmly on the 
 laryngoscope. Then the tissue forceps (Fig. 35) can be accurately 
 placed without the growth slipping away. When the patient coughs up 
 much blood the lamp may become somewhat obscured. Conditions here 
 are very different from work in the tracheo-bronchial tree and in the 
 esophagus because in the latter two regions the tube, when introduced, is 
 allowed to remain throughout the entire procedure, and the swabs with 
 which the field is wiped also at the same time, without any effort, wipe 
 the lamp. In the larynx, however, working as is almost invariably the 
 case, with local anesthesia or with none at all, the direct larj'ngoscope
 
 DIRECT LARYNGOSCOPY. 1(J7 
 
 is frequently withdrawn, and then reintroduced after the patient has 
 been permitted to expectorate tlie blood and mucus. At these inter- 
 vals the sjiatular end of the direct laryngoscojie is wiped by the operator 
 with a square of gauze witliout removal of the light carrier. This wip- 
 ing cleanses the portion of the lamp which emits the light needed. There 
 is no need to cleanse the back of the lamp nor the socket, nor the little 
 pocket in which the lamp lies. In working with the hand lamp the mir- 
 ror is cleansed of the spattered coughed-out secretions at these removals. 
 With the head lam]) the lens front and mirror are to be similarly cleansed 
 and readjusted in the visual axis. With the Claar reflector the mirror 
 and lamp both are cleansed and readjusted to position before the eye. 
 With any of these forehead forms of illumination a nurse should be in- 
 structed as to this cleansing so as to minimize the loss of time. 
 
 In the foregoing the author has referred only to the one kind of 
 forceps. By this he does not wish to disapprove of sliding-punch for- 
 ceps. On the contrary, punch forceps are very useful at times, but their 
 use should not be attempted until the operator is quite familiar w^ith di- 
 rect laryngeal operating, because of the greater liability to such acci- 
 dents as shown at B and C in Fig. 80. 
 
 Taking of a laryngeal specimen for diagnosis. This work is not 
 concerned with diagnosis, yet, it may be said in passing that the diagnosis 
 of carcinoma rests largely upon the histologic examination. The diag- 
 nosis of sarcoma rests largely on the exclusion of laryngeal tuberculosis 
 by histologic and bacillary tissue examinations, animal injections of tis- 
 sue, emulsions, etc. ; and on the exclusion of lues by the therapeutic, 
 the Wasscrniann and the luetin tests. But for biopsy to be of any value 
 either positively or negatively, it is essential to have an ample specimen. 
 In the old days the minute fragment from an uncertain location was a 
 disgrace to the laryngologist, an enormity of injustice to the microsco- 
 pist and, worst of all. to the patient. Too often the so-called "specimen"' 
 w'as, as aptly described by Jonathan Wright (Bib. 582) "A tiny bit of 
 tissue chipped off the surface of a laryngeal growth with a pair of for- 
 ceps, nay, not even surely off the growth, but ])erhaps from some other 
 part of the endo-laryngeal surface in tin- neighborhood of the growth, 
 with the assertion from the operator that it did come from the growth." 
 Direct laryngo.scopy for the removal of a specimen has changed all this. 
 
 The best plan for the removal of the specimen depends upf)n the 
 topography of the laryngeal lesion. If a small growth, it should be re- 
 moved entirely with a goodly jjortion of the normal basal tissues. If a 
 large growlh, and there are objections to entire removal, the edge of the 
 growth including apparently normal as well as neoplastic tissue is ne- 
 cessary. If the larynx is the seat of a diffuse infiltrative process pervad-
 
 108 
 
 DIRECT LARYNGOSCOPV. 
 
 ing nearly the whole larynx a specimen should be taken from at least 
 two locations, preferably axoiding the cords if these are relatively slight- 
 ly involved. In these diffuse infiltrations there is always a suspicion of 
 ])ericlinn(lritis of inflammatory, luetic or tuberculous origin, therefore it 
 is often desirable to include a bit of cartilage in the specimen. About the 
 only place where it is justifiable (in probably benign cases I to remove 
 cartilage is from tiie epiglottis. If the epiglottis is uninvolved the ex- 
 treme tip of the arytenoid, or better still, the cartilage of Santorini or 
 of W'risberg may be removed ; but accuracy is necessary here in order not 
 to do unnecessary damage to the crico-arytenoid joint. After the taking 
 
 Fig. 8i. — Schema of a cross section of the larynx illustrating the outward 
 depth of the ventricle, and also the reason why dyspnea is usually inspiratory. 
 \', B, ventricular bands. V, ventricle. T, thyroid cartilage. C, cricoid cartilage. 
 V, C, vocal cords. In any dyspneic condition such as bilateral paralysis, air pres- 
 sure of attempted inspiration acting upon the floor of the ventricle, V, will force 
 the cords together, whereas in expiration the air-flow upward has no tendency to 
 narrow the glottis. In removing growths from the ventricle the band, \', B, must 
 iie lifted (See Fig. 83). 
 
 of a specimen the patient should be watched for a few days, lest undue 
 reaction supervene from mixed infections getting into the wound, and 
 especially if potassium iodid, which especially predisposes to acute edema 
 has been given. In possibly luetic cases a prompt report must be urged 
 because of the necessity of immediate institution of treatment. In 
 malignancy promptness is also needed. As Sir Felix Semon (Bib. -iD-i) 
 has so ably pointed out, not only should operation closely follow the tak- 
 ing of the specimen; but if the patient should not agree beforehand to 
 radical operation in the event of histologic examination showing malig- 
 nancy, no sjiecimen at all should be taken in cases which clinically seem
 
 DIRIX'T LAKY.VCOSCOl'V. ] U'J 
 
 quite certain to he malignant. Sliouhl the since-discovered effect of ra- 
 dium in controHing malignancy fulfill earK promises, this latter advice, 
 sound in its day, may require modification. 
 
 Removal of growths from the laryngeal ventricle, (irowths in the 
 ventricle, especially when of small size, may lie rendered exceedingly 
 difficult of removal by the oxerhanging projection of the ventricular 
 bands, which, for the time being, exaggerates very much the outward 
 depth of the ventricle. In such cases, general anesthesia may be required 
 and it is ])erfectly justifiable, provided there is no stenosis whatever, and 
 not the slightest dyspnea. With thorough cocainization. however, it is 
 alwavs possible to get these growths by the lateral method of operating. 
 The degree of overhang of the ventricular band especially when in a 
 state of s[)asm is seldom realized (Fig. SI ), Where a growth involv- 
 ing the cord proliably extends far hack into the ventricle, or where a 
 
 B 
 
 Flo. 82. — Pencil sketch of direct laryngoscopic view, sitting patient, shuuing, 
 at ]'). a growth springing from tlie outermost depth of the right ventricle. At ■\, 
 the growth is hidden by the overhang of the ventricular hand. At C. the dntted 
 line indicates the growth under the overhanging ventricular hand. 
 
 growth springs from the ventricle itself and is hidden by the ventricular 
 band as in Fig. 82, it is not necessary to pimch out the ventricular band 
 (as shown to have been accidentally done in Fig. 80) in order to expose 
 the flcKjr of the ventricle and thus render more accurate llie tumor re- 
 mov;d. 
 
 In such a case as that shown in Fig. S'i the head of the i)atient is 
 carried far over to one side after the larynx is exposed (Fig. 8;?). If 
 the tube. E, has not been passed at the side of the tongue it is now 
 slii)])ed over to the lower corner of the mouth. 11. .itid the p.itient's head 
 is tilted o\er to the same >ide wliile the o1iser\er w.'Uclies thrciugli the 
 tube. Tile second assistant must keej) the larynx lixed and in the ver- 
 tical position. The tube is ;idvanccd until the ventricular band is fiat- 
 tened and the growth can be renioxed from the ventricle.
 
 110 
 
 DIRECT LARYNGOSCOPY. 
 
 Removal of large benign tumors of the larynx above the cords. 
 The author often uses for this class of case the alligator punch forceps. 
 Fig. 36. They can be inserted through the author's laryngoscope, but 
 the best way is by the author's "ex-tubal" method. The forceps are in- 
 serted alongside the laryngoscope, which is used only to look through 
 for the accurate ocular guidance of the forceps as shown in the schema 
 Fig. 84. The jaws can be placed and the bite made with great accuracy. 
 The side-slide laryngoscope (Fig. l-")) because of its oval lumen is pre- 
 
 FiG. 83. — Schema illustrating the lateral method of exposing a growth in the 
 ventricle of Morgani, by bending the patient's head to the opposite side while the 
 second assistant externally fixes the larynx with his hand. M, patient's mouth. 
 T, thyroid cartilage. R, right side, L, left. V, B, ventricular band. C, C, vocal 
 cord. The circular drawing indicates the endoscopic view obtainalile by this method. 
 The tube, E, is dropped to the corner of the mouth, B, and the tube is inserted 
 down to R. 
 
 ferred by many operators some of whom leave the slide oft'. In case of 
 still larger tumors with more or less pedunculated base the heavy snare, 
 Fig. 41, may be used to excellent advantage by the "ex-tubal"' method. 
 In some of the author's cases tumors the size of a hen's egg have been 
 thus removed. Sessile growths may be removed by the galvano-cautery 
 snare, but the author prefers forceps. Of course, there could be no 
 hope of thorough removal of malignancy by such means ; and incom- 
 plete removal is rarely if ever justifiable.
 
 DIRKCT I.ARYNCOSCOrY. 
 
 11] 
 
 Aiiipiitalio)! of the cp'u/lottis for palliation of dysphagia in tuber- 
 culosis or malignant disease is an operation easily performed and of 
 benefit where the dysjjhagia is due to ulceration of the epiglottis. It is 
 possible that very early malignancy of the extreme tip can be cured by 
 such means, and the author has had such a successful result in two in- 
 stances. Closure of the air passages to the entrance of food during swal- 
 lowing seems to be a three-fold process. The tilting of the larynx and 
 especially of the arytenoids and the arytenoid a{)proximation are prob- 
 
 /^:;:;;>v 
 
 ♦•'> 
 
 ) 
 
 Fig. 84. — Sclicma illustrating removal nf a tumor from the upper part of the 
 laryn.K liy the author's "ex-tuhal" method for large tumors. The large alligator 
 basket punch forceps, F, is inserted from the right corner of the mouth, and the 
 jaws are placed over the tumor, T, under guidance of the eye looking through the 
 laryngoscope, L. This method is not used for small tumors. It is excellent for 
 amputation of the epiglottis viith these same punch forceps (Fig. 36) or with the 
 heavy snare. (Fig. 41.) 
 
 ablv the chief factors. In addition to this, however, there is the closure 
 of the ventricular bands below and the capping by the epiglottis above. 
 The least important of the three seems to be the epiglottis and it can 
 very readily be disjiensed with if necessary to relieve pain or cure dis- 
 ease. Probably its chief function is to act as a snow plow in splitting 
 the food bolus and drifting the two portions laterally into the pyriforin 
 sinuses thus directing the food bolus ])ast the adilus laryngis. Mr. Wal- 
 ter O. lldwarth states that the epiglottis lias imthini,^ wlialc\or to do will'
 
 113 DIRECT LARYNGOSCOPY. 
 
 laryngeal closure during swallowing. As a clinical fact we know that 
 amputation of the epiglottis is not often followed hy serious .symptoms 
 and results in the relief of pain are excellent. Lockard ( llih. ;!4G ) has 
 collected statistics on the results in tuberculosis. It would not be easy 
 to get out more than the projecting part of the normal epiglottis, but it 
 is not difficult to remove all of the involved portions. The projecting 
 part may be amputated with the heavy snare shown in Fig. 41, and this 
 is the better way in those rare cases of disease limited to the tip be- 
 cause of the en masse removal. In more general involvement either the 
 snare or the large basket alligator punch forceps ma\- be used. With 
 either instrument it is best to operate by the author's "ex-tuljal" method 
 shown in the schema. Fig. 84. 
 
 Endolarytujcal operations farorhu/ dci'elopwcnt of ad: cntitioits t'O- 
 cal cords. In some instances liberation of adhesions will favor the for- 
 mation of adventitious vocal cords. In other instances where there is 
 tension from contraction of cicatricial tissue hampering mobilitv of the 
 arytenoids an incision designed to relieve the tension and supply a re- 
 
 FlG. 85. — Autlior's laryngeal knife, 30 cm. long. Illustruliun reuruduccd from 
 the earlier volume. ' 
 
 dundancy of tissue for later absorption will bring back the voice as illus- 
 trated in the case cited m the section of this work that deals with papil- 
 loma. For such incisions the author's laryngeal knife. Fig. 8."), is ex- 
 cellent. The sharp anterior commissure is essential to good phonation. 
 In Fig. 15, Plate 1, is illustrated a case in which the action of the laryn- 
 geal musculature was unable to approximate and draw tense the adven- 
 titious vocal bands. The patient, a man of thirty years, when convales- 
 cent from a very severe attack of typhoid fever became dyspneic and 
 was tracheotomized by Dr. James \V. McFarlane. When the perichon- 
 dritis had subsided the larynx remained stenosed by cicatricial tissue, and 
 the case was transferred to the author's service at the Western Pennsyl- 
 vania Hospital for decannulation. The stenosis was cured by larvngos- 
 tomy by the author's method as described in a later chapter. After 
 decannulation and plastic closure the patient could not speak louder 
 than a whisper because of inability of the laryngeal musculature to ap- 
 ])roximate and draw tense the cicatricial adventitious vocal bands (Fig. 
 1-"), Plate 1 ). With a sliding punch forceps the author cleared the anterior 
 commissure of all tissue out to the perichondrium, as shown bv the 
 dotted line, with excellent vocal results. In this kind of case, it is
 
 niRI-CT LARYNGOSCOPY. 113 
 
 alisoliiteiv necessary to remove the tissue anteriorly very radically but to 
 harm the tissue at the sides as little as possihle. There was a thick 
 redundancy of tissue not under tension. With a thin band-like web 
 under tension it is usually better to incise with the knife as in the case 
 referred to under "Papilloma." 
 
 Eudosco/'ic evisceration of the larynx is a procedure which will 
 cure a few cases of cicatricial laryngeal stenosis especially those where 
 the cicatrices are thin and web-like. Illustrative cases are shown in 
 Plate 1. Fig. 1 shows a post-dijjhtheritic stenosis in a boy of fourteen 
 years admitted to the Western Pennsylvania HosjMtal for decannulation. 
 .\n incision was made in the plane of the glottis, so that the slide inuicb- 
 forceps could be inserted. All of the endolaryngeal tissue that could 
 be removed without injury to the arytenoid cartilage was extirpated, the 
 efifort Ijeing made to lay bare the perichondrium of the laryngeal wall, 
 as shown schematically in Fig. 8(1. Healing was prompt but left a 
 slight recurrence of the cicatricial tissue in the anterior commissure. 
 Thorough removal of this with a pointed slide-forceps was followed by 
 an excellent result (Fig. ."), Plate 1 ) both as to voice and cure of stenosis. 
 He was seen two years after decannulation and was learning a trade in 
 a mill. A similar case was that of a man. aged 40 years, who applied to 
 the Eye and Ear Hospital Dispensary for decannulation. He had been 
 tracheotomized during typhoid fever about a vear before. The larynx 
 was occluded by a thin membranous cicatrix which left only a small 
 opening posteriorly (Fig. 1, Plate 1 ). There was slight arytenoid move- 
 ment on both sides. The laryn.x was eviscerated as in the previous case, 
 but required two subsecjuent removals of tissue to clear the anterior 
 commissure. .An excellent result was uUinialcly obtained (Fig. 8, Plate 
 ] ) and the [Jatient was decannulated after two months' watching. The 
 voice was loud, though rough, and there was no recurrence of the 
 dyspnea when seen two years later. In three other cases the same meth- 
 od was not sufliciently successful to permit decannulation but the method 
 is well worthy of trial before resorting to laryngiistf)mv. .\ simple punch- 
 ing out of the occluding membrane is not sulTicient. .\n effort should be 
 made to remove all of the tissue in the larynx clear out to the perichon- 
 drium, but without removing any part of either arytenoid cartilage, in 
 non-])aralytic cases. In cases of posticus paralysis the excision may be 
 carried farther back, excising a jiortion of the processus vocalis of the 
 arytenoids. 
 
 I'oca! results. Two classes of cases must be considered. 
 
 1. In cases of laryngeal stenosis in which no air is going through 
 the larynx on expiration with the cannula temporarily occluded with the 
 finger, the patient of course has no voice except the "buccal voice" like
 
 1 I 4 DIRKCT LARYNGOSCOPY. 
 
 that developed by the laryngectomized patient. These patients can be 
 promised a good whispered voice immediately after operation. Phona- 
 tion will depend on the conditions mentioned below in the next class of 
 cases. 
 
 2. In cases of laryngeal stenosis in which anv e.xpiratorv air at all 
 is going throtigh the laryn.x when the tube is temporarih- occluded with 
 the finger, the voice is usually fairly good. Therefore, one of the first 
 questions to be considered is in regard to the voice after operation. The 
 author has demonstrated that the most important factor in the produc- 
 tion of an adventitious cord, after operative or morbid loss of the true 
 cord, is the traction of the arytenoid. The thousands of pulls dailv end 
 in a band which more or less perfectly in appearance and function re- 
 places the lost cord. So close is the resemblance in some cases that ex- 
 
 FiG. S6. — Schema showing endoscopic evisceration of the laryn.x for posticus 
 paralysis. The attempt is made with the shding punch forceps (Fig. 37) to eviscer- 
 ate all of the laryngeal tissue inside of the dotted line. It is practically an impos- 
 sibility to remove all of the tissue hut the attempt will relieve the stenosis in some 
 instances. In non-paralytic conditions it is very necessary to avoid injuring the 
 arytenoid cartilages ; for in these cases good arytenoid mobility will assist in the 
 formation of an adventitious cord. 
 
 pert laryngologists are unable to say whether a cord is original or ad- 
 ventitious. To get such results, however, it is absolutely necessary that 
 there shall be mobility of the cricoarytenoid joint. Of course the whis- 
 pered voice will never be lost so long as the respiratory air passes through 
 the larynx. The "stage whisper," for which no cord is necessary, may 
 to be very loud, and in soine instances the ventricular bands will approxi- 
 mate and phonate, but to phonate eft'ectively requires a cord, natural or 
 adventitious. The voice of the ventricular band is deep and rough, and 
 lacks flexibility. The ventricular band, however, is mostly removed in 
 endolarv-ngeal evisceration. From his results with endolarA'ngeal eviscera- 
 tion, the author believes that, in all forms of non-malignant chronic 
 laryngeal stenosis a good chance of a cure of the stenosis may be prom- 
 ised in any case in which there is not too much loss of the cartilage 
 which maintains the patulence of the laryngeal box. An ultimate good
 
 niRKCT I.ARYXCOSCOPV. 11.J 
 
 vuicc can be [jromised in all cases in which there remains good arylenoiil 
 mobility. A fairly loud, though rough and inflexible voice, can be prom- 
 ised in any case without mobility. Endolaryngeal evisceration should be 
 tried before resorting to laryngostomy. 
 
 Galvano-cauterizatiou for chronic hypertrophic laryui/col stenosis. 
 The author has had e.xcellent results from the galvano-cauterization of 
 chronic subglottic edema or hyperplasia seen in children after diphtheria. 
 In some instances the children had been intubated in others tracheotom- 
 ized for dyspnea during the height of the diphtheritic process. An illus- 
 trative case is shown in Fig. 87, referred to the author by Dr. Torian for 
 extuljation. A boy of two years, after laryngeal diphtheria requiring in- 
 tubation, could not be extubated because of a recurrence of dyspnea 
 within a few minutes of the removal of the intuliation tube. A number 
 of attempts had been made during two months. In the recimibent posi- 
 tion the author remo\eil the intubation tulie tlirou.nh the direct laryng(j- 
 
 ®®®® 
 
 Fk;. S7. — IHrt'ct view. Recumbent pcisitimi. Illustration ol the effectiveness of 
 galvano-cauterization of post-diiilitheritic subglottic stenosis. A, shows the larynx 
 immediately after the reinoval of the intubation tube. B, five minutes later the 
 hyprrtropliic subglottic masses on each side are seen to have closed in like intumes- 
 cent turbinals. C, the left mass has been cauterized and is bound down by a linear 
 cicatrix parallel with the long axis of the trachea. D, shows the larynx after cure 
 by repeated cauterizations. 
 
 scope. A subglottic mass could be seen on each side, biu an ample chink 
 was left for breathing, as shown at A. Fig. 87. At the end of live min- 
 utes the masses had swollen until they almost met in the median line and 
 the child became intensely cyanotic. A bronchoscope was inserted and 
 left in the trachea while a tracheotomy was done. Later the galvano- 
 cautery knife was used to incise the hypertrophic masses, one such in- 
 cision Ijeing shown at C. .\ perfect cure resulted and the child was re- 
 ported well six months later, .\notlier case, that of a young child 
 tracheotomized for diphtheria three months previously, was referred to 
 the author for decannulation by Dr. j. W. .Mtn-jihy. Galvano-cauteriza- 
 tion of the subglottic hypertrophies, as in the jireviously mentioned case.
 
 116 
 
 DIRECT LARYNGOSCOPY. 
 
 resulted in a complete and permanent cnre. It was still well a year and 
 a half later. In one case admitted to the Western I'ennsylvania Hospi- 
 tal subo^lottic edema followed an influenzal tracheitis for which tracheot- 
 om\- had been done. The same method resulted in perfect cure that 
 has borne the test of time. The method is ideal for hypertrophic condi- 
 tions, Ijut is not so well adapted to cicatricial stenoses, though the au- 
 thor had a [jartial result in one case. 
 
 Galvano-cautery puncture has superseded all caustics for laryngeal 
 use. The excellent results achieved by Heryng, Hajek and jMermod 
 (Bib. 407) in the galvano-caustic treatment of tuberculosis, led the au- 
 thor to develop the endoscopic technic and his results have been very sat- 
 isfactory. This plan of treatment has also been advocated in an excellent 
 monogra])h ( Bib. 20) by Prof. Louis Bar of Xice. The use of the curette 
 
 Fic. 88. — Direct view (sitting position) of a tnl)crculous larynx, in a girl of 
 17 years. The large club-shaped infiltrations in the right hand view were reduced 
 by three cauterizations at three weeks' intervals to the size shown on the left hand. 
 Slight sloughing occurred near the right arytenoid (upper left quadrant of the left 
 circle). This is a rare sequel, and it did ui> harm. 
 
 and of lactic acid have been quite generally abandoned since such abun- 
 dant evidence has been forthcoming, proving the great usefulness of the 
 galvano-cautery in the treatment of tuberculous infiltrations in the larynx 
 and all of the laryngologists who have used the direct methods for these 
 apjilications are enthusiastic as to the precision with which the caustic 
 point can be ap[)lied. The direct method exposes to view the anterior 
 surface of the posterior wall of the arytenoid masses, and thus the point 
 can lie applied practically per[)cndicularly to the surface, which is in 
 great contrast to the indirect niethod by which a more or less lateral ap- 
 plication of the poiiU renders accurate puncture more difficult, and some- 
 times im])ossible. I'urthermore, it matters little how intolerant the pa- 
 tient may be to the laryngoscopic mirror; he cannot in any case what-
 
 DIRECT LAKVNC.OSCOPV. 117 
 
 soever prevciu tlie skillful oi'eialor from makini; an accurate applica- 
 tion. Direct larxngoscopy has opened u\> a new field in the local treat- 
 ment of tul)erciilcus lesions. It seems eiptally well adapted to ulcerative 
 and non-ulcerated infiltrations. Of course, it is sufiject to the same 
 general and local contraindications that apply to any surgical treatment 
 of laryngeal tuberculosis, especially the inadvisability in cases with ad- 
 vanced pulmonary disease. In severely stenosed larynges a tracheotomy 
 should first be done, for though tlic reaction is slight, it might be sufti- 
 cient to close the narrowed glottis. Application of the galvano-cautery 
 to tuberculous lesions below the larynx has been unsatisfactory in the 
 author's hands. The technic is simple. The author uses the electrode 
 illustrated in his earlier work I l!ib. 2(i9) with hard rubber insulation vul- 
 canized onto the copjjcr conductors insuring cleanliness. In a few in- 
 stances a right-angled point is useful but usually the straight point is 
 better. The larynx is anesthetized locally and exposed with the direct 
 laryngoscope, the patient sitting. The rheostat having been previously 
 adjusted to heat the electrode to a very nearly white heat, the circuit 
 is broken and the electrode is introduced cold. \\ hen the point is in 
 contact with the desired location the current is turned on and the point 
 thrust in as deeply as desired. I'sually it should j)enetrate until a firm 
 resistance is felt ; but care must be used not to damage the cricoarytenoid 
 joint. The circuit is broken at the instant of withdrawal. Punctures 
 should be made as nearly [lerpendicular to the surface as possible, so as 
 to minimize the destruction of epithelium, and to minimize the reaction 
 which is greater after a broail suj)erficial caiUerization. The reaction 
 is usually slight, a gray tibrinous slough detaching itself in a few days. 
 In one c;ise the author h.id rather extensive sloughing, but it left no bail 
 result. Xo after-treatment is needed. Cautery-] )unctures should be re- 
 I)eated every two or three weeks selecting a new location each time 
 until the desired residt is obtained. 
 
 .Iftcr-iarc. After any endolaryngeal operation, cleanliness of the 
 mouth must be insured by brushing the teeth after taking food, anil by 
 the rinsing of the mouth with alcohol 1 part to 'i of water. If the oper- 
 ative w'ound extends out of the interior of the larynx, sterile water and 
 sterile liquid food should be given for four days. \o local applications 
 are needed. Comjilications should, of course, be watched for. In all 
 cases, whether lr;icheotiimized or not. ihe ]>alient sliouKl be \\;itched Ijv :i 
 special tracheal nurse. In cases not tracheolomized, the |)ossibilitv of 
 laryngeal dyspnea sliouhl be in the mind of the sin-geon and the muse. 
 Inspiratory indrawing arunnd the cl;i\icles, inspirators indr.iu ini; almve 
 the sternum ;uid .'it the e|iigaslriinn. and a fiir\\,ird movement (if the
 
 118 DIRECT LARYNGOSCOPY. 
 
 chin at each inspiration are the danger signs demanding immediate 
 tracheotomy. Cyanosis should not be waited for. 
 
 Complications during cndolaryngeal operation are very rare. Dysp- 
 nea mav increase if the larynx is stenotic before ojieration. and tracheot- 
 omy may be required in such cases. Idiosyncracy to cocaine may induce 
 toxic symptoms. The sight and taste of blood may nauseate the pa- 
 tient, causing syncope. Serious hemorrhage could occur only in a hemo- 
 phile, and it would be long after the operation before the loss of blood 
 would be serious. Injury to an incisor tooth can only come from mis- 
 directed eilfort in a false position. The bite-block, however, unless care- 
 fully handled might damage a frail tooth, "bridge-work," a capped tooth, 
 or other dental fixture. The loss of a portion of an instrument down 
 into the air passage is a complication to be avoided by having well made 
 instruments and especially by careful inspection from time to time. 
 
 Complications after cndolaryngeal operations are unusual, yet all 
 patients should be watched closely. Inflammatory reaction is rarely se- 
 vere if the aseptic technic has been without a slip. Cervical cellulitis 
 has been known to follow carelessness in this respect. Edema of the 
 larynx occasionally occurs and in rare instances necessitates tracheot- 
 omy. Emphysema of the neck occurs \ery rarely. It does not require 
 treatment ordinarily; but mav be treated in the usual way if desired. 
 Hemorrhage sufficient to re(|uire attention, either at operation or sub- 
 sequently, is very rare, except in hemophiles. Hemorrhage within the 
 larynx of a hemophile can be stopped by packing a roll of gauze tightly 
 down into the laryn.x from above, if the patient is tracheotomized ; and 
 if not, tracheotomy should be done. This was required in one case of 
 the author, that of a hemophile. Styptics are very objectionable for 
 laryngeal use, and have been known to set up serious lung complications. 
 Mermod (Bib. 384) advises morphine subcutaneously. 
 
 DIRECT L.\RYNGOSCOPV, ADULT P.VTIK.NT, RKCUMUKXT. 
 
 Exposure of the larynx in the recumbent patient is precisely the 
 same as in the sitting patient so far as the relation of the instrument to 
 the patient is concerned, and so far as the position of the head and neck 
 of the patient relatively to the patient's body is concerned. The manner 
 of grasping the handle of the direct laryngoscope, however, varies, and 
 the endoscopic image is reversed with reference to the operator's eve 
 both in the vertical and the horizontal direction. What was to the 
 operator the left side of the image now is the right, and the anterior 
 commissure which before was at the bottom of the circular endoscopic 
 picture, is now at tiie top of ihe circle. For this reasoiL practice in the
 
 DIRECT LARYNGOSCOPY. 
 
 119 
 
 sitting position is of hut little avail and a large amount of practice is 
 re<]uired in the recumhent position, because much of the endoscopic work, 
 and practically all of the foreign body work in the larynx and the 
 tracheo-bronchial tree is, or should be, done in the recumbent position. 
 The best position for the recumbent patient is that of Boyce, as de- 
 scribed in a previous cha|)ter and shown in Fig. T"2 with the head raised 
 high and fully extended. I'nder no circumstances during direct 
 
 Fig. 89. — Direct laryngoscopy, recumbent patient. The second assistant is sitting 
 holding the head in the Boycc position, his left forearm on his /(•// thigh, his left 
 foot on a stool whose top is 65 cm. lower than the table-top. His left hand is on 
 the patient's sterile-covered scalp, the thinnb on the forehead, the fingers imder the 
 occiput, making forced extension. The riylit forearm passes under the neck of the 
 patient, so that the index finger of the right hand holds the bite block in the left 
 corner of the patient's mouth. The operator stands, but may sit on a stool of the 
 same height as that on which the second assistant is sittini;. .\n enlarged view of 
 the operator's hands is shown in Fig. 90. 
 
 larj'pgoscopy should the head be allowed to hang over the end of the 
 table in the Rose position. 
 
 I'efore a start is made, everv detail ineminiied luider the head of 
 operating room organization >honl(l have been carried out. l'",very in- 
 strument that might jiossibly be needed shouM be sterile and ready, 
 sponge holders armed, assistants in jiosition, including those who are to 
 hold the patient's arms and legs, as well as the one who holds the head
 
 120 
 
 DIRECT LAKYNCOSCOPY. 
 
 and the other who passes the needed instruments. The second assist- 
 ant who holds the head, then takes the sterile cap, slips it over the pa- 
 tient's head until the opening comes opposite the mouth of the patient. 
 Then he grasps the patieiu's head and elevates it while the unsterile 
 nurse drops the head-hoard or shortens down the back-board of the Dr. 
 French table, as the case ma\- be, leaving the jiatient's shoulders as far as 
 the ridge of the scapula, as well as the head and neck of the patient, out 
 in the air supported bv the second assistant, who nnw raises the head 
 
 Fig. go. — Direct lar\ngoscopy, recumbent patient. The laryngoscope is held in 
 the left hand. The first, second and third fingers of the right hand are used to 
 pull down the uppei lip of the patient to prevent pinching the lip 1)et\vecn the 
 laryngoscope and the teeth. The camera being above the patient .gives a false im- 
 pression of the position of the head and chest. The chest is really very much lower 
 than the head. 
 
 wilh the left hand, his thumb being on the patient's forehead, while the 
 right hand is passed below the patient's neck so that the thimble gag on 
 his first finger can be inserted between the teeth at the left side of the 
 patient's mouth, the second assistant being on the right hand side of the 
 patient (Fig. 89). The most important part of the procedure at this 
 point is the high elevation of the patient's head. Under no circum- 
 stances must it at this stage be jiermitted to fall until the vertex is lower 
 than the table top.
 
 DIRKCT LAKYNC.OSIOI'V. 
 
 1-21 
 
 The introduction of the direct laryngoscope and the exposure of the 
 larynx may best, for clearness of description as well as for promptness 
 and eft'ectiveness of execution, be divided into two stages. 
 
 1. Exposure and identification of the epiglottis. 
 
 2. Elevation of the epiglottis and all the tissues attached to the 
 hyoid bone so as to expose the larynx to direct view. 
 
 The tongue of the patient need not be held out. The patient is 
 sim])ly told to open his mouth, or, in the case of general anesthesia, the 
 mouth is opened and tlie bite-block, Fig. 3!l, is inserted. The direct laryn- 
 goscope is grasped, as shown in Fig. HO. which is perferable to that 
 shown in Fig. 59. Absolutely always and in\arialily the left hand must 
 be used to grasp the laryngoscope. If this be not done, the operator will 
 be seriously handicapped when it comes to passing a bronchoscope, or to 
 
 Fig. 91. — End of first stage of direct laryngoscopy, recumbent adult patient. 
 The epiglottis is e.\posed by a stroni^ lifting movement of ibe spaUiln tip on the 
 tongue anterior to the epiglottis. 
 
 operate on the larynx, because the right hand should be free just as 
 soon as it is through with its very im])ortant duty of drawing the upper 
 lip toward the nose of the patient in order to prevent the lip getting 
 pinclicd between the laryngoscojic and the upper teeth. The laryngoscoiie 
 is passed into the patient's mouth posterior to the dorsum of the tongue, 
 exactly in the middle line, particular note being taken that the patient's 
 head is exactly square with the body : that is, not deviated to either side. 
 nor rotated. The dorsum of the tongue is now pressed anteriorly, in 
 other words, lifted, in the recumbent position of the i)alient, until tlu- 
 epiglottis comes into view. Great care mtist be taken not to pass the 
 spatular lip beyimd the epiglottis in this first stage; and it is better to 
 elevate the dorsum of the tongue from time to time in order tlial there 
 shall be no danger of the epiglottis being overridden. When the epiglot- 
 tis is seen to ])roject into the endoscopic field, as shown in Fig. !•] , the 
 first stage is completed.
 
 ]22 DIRKCT LARYNGOSCOPY. 
 
 Second sta(/c. Tlie spatular end of the direct laryngoscope is in- 
 serted to a distance of, on the average, about 1 cm. and then the larynx 
 is exposed by a motion that is best described as a suspension of the head 
 and neck of the patient on the tip of the spatular end of the laryngo- 
 scope Fig. ')■■?. In other words we try to lift the jiatient's head with 
 
 Fig. Q2. — Schema illustrating the technic of direct laryngoscopy on the recum- 
 bent patient. The motion is imparted to the tip of the laryngoscope as if to lift 
 the patient by his hyoid bone. The portion of the table to the left of the word 
 "TABLE" may be dropped or not, but the back of the head must never go lower 
 than here shown, for direct laryngoscopy. The table may be used as a rest for the 
 operator's left elbow to take the weight of the head. The author prefers head 
 section of the table dropped. (Note that in bronchoscopy and esophagoscopy the 
 head section of the table must be dropped, so as to leave the head and neck of the 
 patient out in the air, supported by the second assistant.) 
 
 the tip of the speculum. The assistant, consequently, must not take all 
 the weight of the head. Particular care must be taken at this stage not 
 to pry upon the upper teeth ; but rather to impart a lifting motion with 
 the tip of the speculum without depressing the jiroximal tubular orifice. 
 If the teeth are used as a fulcrum, there will be a tendency to pry the 
 head downward, which is a distinct disadvantage; because the head
 
 DIRECT LARYXGOSCOPY. 
 
 133 
 
 should be kept high as well as extended. The view first obtained of the 
 larynx is, to the beginner, often unsatisfactory, because the larynx is in 
 a state of spasm ; and usually but little is to be seen but two rounded 
 masses, and anterior to them the ventricular bands in more or less close 
 apposition hiding the cords (Fig. i)3). Of course in deep anesthesia, 
 or often even in the very thoroughly locally anesthetized larynx, this 
 spasm does not occur, and the second stage at once reveals the cords 
 moving rhythmically with ins])ir,ition and expiration. It is customary 
 with some endoscopists to ask the jiatient to phonate continuously in 
 order to render more easy the identification of the glottic chink and 
 vocal cords. It is very much Ijetlcr. however, in the author's o])inion, 
 to insist U])on the jjatient breathing steadily and deeply: but the begin- 
 
 1-ic;. t).?. — Lndoscopic view at tlie eiul ol the si-coiul stage of direct laryngoscopy. 
 Recumbent patient. Laryn.v exposed. Waiting for larynx to relax its spasmodic 
 contraction. A deep inspiration will then show the cords beautifully exposed. In 
 the full relaxation of deep anesthesia this spasmodic closure does not exist and 
 the second stage reveals the cords opening and closing rli\ thniirally with inspira- 
 tion and expiration. 
 
 ner should try both ways. If his attention is fixed upon this before- 
 hand, almost any adult will keep on breathing if the command is re- 
 peated frequently. 
 
 DifticiiUics of dirrcl laryngoscopy. 'I'he difficulties may be classi- 
 fied under two heads: Those that pertain to the patient and those that 
 pertain to the operator. 
 
 The ease of exposure of the larynx varies within very wide limits 
 in adult patients. There is very little difference in children. A very 
 muscular, .stout adult with a short, thick neck and a full row of ujiiier 
 teeth will usually be very much more difficnlt than will a flaccid, slender 
 patient with a long neck and u[)per teeth absent, liut it must be re- 
 membered that there is absolutely no patient whatever, whose larynx 
 cannot be exposed to direct view with the .sole exception of a i)aticnt 
 
 ^
 
 12J: P]RKCT LARVXGOSCOrv. 
 
 with ankylosed jaws, preventing the opening of the muutli. so that while 
 the ease of exposure may vary within wide hniits, there is none m whom 
 direct laryngoscopy is impossible. 
 
 Failure to expose the epiglottis is usually due to too great haste to 
 enter the speculum all the way down. The efforts should be rather to 
 lift the tongue at its dorsum and gradually to slide the spatula down- 
 ward so as to get into the glossoepiglottic fossa. When this is done, the 
 epiglottis will loom large. In some cases the anterior one-third of the 
 larynx does not readilv come into view, because it is drawn upon by the 
 elevation of the hyoid bone. To expose this anterior one-third all the way 
 to the anterior commissure, it is in some cases necessary for an assist- 
 ant other than the one who holds the head to make counterpressure on 
 the thyroid cartilage externally, pushing the larynx backward (downward 
 in the recumbent patient). Either lateral wall can be made prominent, 
 and the whole larynx can be fixed. To get the best results from counter- 
 pressure, it is necessary to be careful that the direct laryngoscope is not 
 too deeply inserted. It should not be deeper than is necessary to hold 
 the epiglottis. In various laryngeal operations, this counterpressure by 
 an assistant trained to the work, is of great help to the operator bv fix- 
 ing the larynx, turning it to one side or to the other, as requiretl, to 
 bring into view one or the other side of the larynx. Practice together 
 on the part of the operator and his assistant, in this respect as in every 
 other, will produce results by "team work" unobtainable in any other 
 wa)-. In most instances the best results are obtained by having the as- 
 sistant fix the thyroid cartilage in a vertical position, while the head, 
 only, of the patient is turned over to the side opposite to that on which 
 the growth is located. This side method of operating is shown for the 
 sitting position in Fig. 80. It is relatively the same in the recumbent 
 patient. After learning how, passing the tube at the side instead of over 
 the dorsum of the tongue will render the most difficult case easy. 
 
 The difficulties that pertain to the operator himself, are chiefly due 
 to lack of practice. Absolutely nothing will dispense with the necessity 
 of continued practice, and while much may be done, as mentioned under 
 the head of acquiring skill, nothing will take the place of frequent work 
 ui)on the patient in the recumbent position. As one of the greatest 
 difficulties is caused by the spasmodic contractions, not onlv of the 
 laryngeal muscles, but also of the muscles of the neck, and especiallv all 
 of the muscles attached to the hyoid bone, it will be of great assistance 
 if the operator can have the advantage of acquiring the knack of ex- 
 posure of the larynx first in patients deeply generally anesthetized. 
 
 One of the greatest difficulties of the beginner is in recognizing the 
 landmarks. We are so accustomed to seeing classical pictures of the
 
 DIRECT LARYNGOSCOPY. 133 
 
 laryr.x during inspiration, expiration and phonalion, thai we are quite 
 confused and discouraged when we do not sec such a picture by the 
 direct method. It must he rememhcred, however, that in proceeding by the 
 old inchrect method, observation is usually terminated when the patient 
 has very much of spasmodic contraction about the pharynx and larynx, 
 while in direct laryngoscopy these sjiasmodic contractions are no bar to 
 a continuation of the examination; and we must learn to recognize the 
 landmarks in the state of a high degree of spasm. This, of course, is 
 especially necessary in working without any anesthetic, general or local, 
 as in the case of children. We must therefore fix in our minds the 
 previously mentioned landmarks, namely, the two rounded eminences, 
 corresponding to the arytenoids. It is only on deep inspiration that aity- 
 thing like a typical picture of the larynx will be seen. Therefore, we 
 must terminate our search upon the identification of the two rounded 
 masses and wait for the inspiratory opening to get a view of the in- 
 terior of the larynx. Herein consists one of the great advantages of 
 w^orking with local anesthesia. Should the patient be anesthetized, though 
 not c|uite deeply enough to abolish the reflexes about the ])harynx and 
 larynx, and especially if the patient has been given chloroform along 
 with any of the opium derivatives, it is a very serious risk to wait very 
 long for the glottis to open, ijccause of the paralyzing effect of choloro- 
 form and the opium deri\atives upon the respiratory center. On the 
 other hand, when a local anesthetic alone is being used, we can safely wait 
 indefinitely for the patient to breathe, meanwhile telling him to take a 
 deep breath and not to hold it, and reassuring him that he can get his 
 breath perfectly well if he only will. It is only in infants and very 
 young cliildren ih.it the injunction "keep on breathing"' will not he fol- 
 lowed promptly by an inspiration, but as these are examined without any 
 anesthetic, general or local, we can wait indefinitely for the opening in- 
 spiration, excejit in very dyspneic cases. 
 
 Hlbou'-rrst ['osltion. If the operator is not strong in tin- wrist 
 and forearm he may exjierience fatigue in holding the lar\nx of the 
 recumbent ])alient ex])osed for any length of time. ]>y this it is not 
 meant that great strength is re<|uired. Like most similar procedures 
 there is more in the knack than brute strength. If endurance is being 
 taxed the aiUlii}r's elbow-rest position will enable the operator to work 
 for any length of time that could possibly be needed for an endolaryn- 
 geal procediue. The head hoard of the table is not dropped for this 
 position. If ;dready dropjied the head board is raised to a level position. 
 The operator's left elbow rests on the table beside the patient's head, 
 the head being suspended on the tip of the laryngoscope. The operator 
 sits on a stool at the head of the table facing towards the patient's feet.
 
 126 DIRECT LARYNGOSCOPY. 
 
 Suspension hirymjoscopy devised by Prof. Killian to render direct 
 laryngoscopy in the recumbent position easier, will be treated in a separ- 
 ate chapter by the great master himself. 
 
 DIRECT LARYNGOSCOPY IN CHILDREN. 
 
 For those who have practiced it, direct laryngoscopy in children, 
 for diagnosis, is a simple, easy matter requiring but a minute or less. 
 without anesthesia, general or local. On the other hand, for the be- 
 ginner it may require twenty minutes at the end of which time he may 
 not have had a good view of the larynx. The procedure is easily learned 
 and for five reasons it is an absolute necessity that every laryngologist 
 be able to make the examination without any anesthesia : 
 
 1. Anesthesia is unnecessary. 
 
 2. It is extremely dangerous in dyspneic patients. 
 
 3. It is inadmissable in a case which may jirove to be diphtheria. 
 
 4. If anesthesia is to be used, direct laryngoscopy will never reach 
 its full degree of usefulness, because anesthesia makes a major pro- 
 cedure out of a minor. 
 
 5. There is no more reason for anesthetizing a child to look at its 
 larvnx than to anesthetize it to feel for adenoids with the finger. 
 
 \\'hate\er may be said on the subject of anesthesia for bronchos- 
 copy and esophagoscopy in children, no one can deny that the larynx 
 of any child can be examined quickly, painlessl}' and satisfactorily with- 
 out anesthesia, general or local. By this it is not meant that a diagnosis 
 can always be reached, but the nature of dyspnea or croupy cough can 
 almost always be determined. Seeing the larynx of an adult by the in- 
 direct method does not always mean a diagnosis. Cocaine in children 
 is dangerous and its application is more of an annoyance than the ex- 
 amination. This matter has been more fully dealt with in the chapter 
 on anesthesia. The brief mention here is to emphasize a matter in 
 which there has been much misunderstanding and many misleading state- 
 ments. 
 
 In leaving the subject, the author wishes to state that any operator 
 who uses a general anesthetic on dyspneic children will some day re- 
 gret it, because of the death of a child from a needless procedure. If 
 the operator must have a general anesthetic, he should do a preliminarv 
 tracheotomy. 
 
 Inslniinents. For a diagnostic direct laryngoscopy in children the 
 following are needed : 
 
 ] child's direct laryngoscope. 
 1 double bronchoscopic battery.
 
 DIRIX'T I.ARYNGOSCOl'V. 127 
 
 1 laryngeal alligator forceps, (Mosher's). 
 
 1 bite block. 
 Tracheotomy instruments. 
 
 These are the bare necessities. The author prefers to prepare for a 
 bronchoscopy also, with sponge holders, sponges and bronchoscopic for- 
 ceps complete, as will be given on a future page ; because very often the 
 cause of the trouble may not be found in the larynx and not to inves- 
 tigate the trachea leaves a doubt. If children be examined in the re- 
 cumbent position and fasting there will be little trouble with secretions, 
 consequently swabs and aspirators will not be absolutely necessary for 
 mere diagnostic examinations of the larynx only. On the other hand, 
 if the child has had food or water w'ithin four hours, fluid from the 
 stomach will be plentiful. If examined in the sitting position, which is 
 always inadvisable in children, there may be much trouble from fluids over- 
 flowing into the larynx. I'nder no circumstances should the endoscopist 
 start to examine a case of supposed foreign body in the lar_\ nx with only 
 a laryngoscopic outfit. Everytiiing needed for a direct laryngoscopy, bron- 
 choscopy and esophagoscopy should be ready in order to get the intruder 
 wherever it may be. 
 
 For operative work on the child's larynx, such as the removal of 
 papillomata, we must add to the al>o\e list: 
 
 4 sponge holders. 
 
 2 dozen of !) mm. sponges. 
 Tissue forceps. 
 
 Tracheotomy instruments are listed and >iioiild always be sterile and 
 ready. Xot that the procedure itself would ever, in any normal child, 
 render tracheotomv necessary ; but so many of the diseases for which 
 a child is laryngoscoped diagnostically are stenotic in character that the 
 endoscopist should be prepared for a tracheotom\. 
 
 Direct lar\'ngoscop\ of children as compared to direct laryiujuscopy 
 of adults. A child is more difticult to examine without anesthesia than 
 the easiest of adults with local anesthesia; but there is little difference 
 between one child and another, and any child is easier without anes- 
 thesia than the more difticult adults with good local anesthesia. An>- 
 hnni.nn bein^, however, can be satisfactorily laryngoscoped directly if his 
 mouth can be o|)ene(l. In children, the difliculties of direct laryngoscopy 
 are not increased by smallness of the tube, for the lumen of the child's 
 laryngoscope of the author's design, is plenty large ( 1 cm.l. Tiie dilti- 
 culties lie rather in liie very flexible ejtiglottis of children, and the fact 
 that the entire larynx, though relatively higher than in the adult, is more 
 movable an<l has a greater tendency to retreat downw.ird during ex
 
 128 DIRECT LARYNGOSCOPV. 
 
 amination and thus witlidraw the epiglottis immediately after the aryte- 
 noids are exposed. The larynx is drawn downward during normal in- 
 spiration. In cases of dyspnea the exaggerated activity of all the res- 
 piratory musculature pulls the larynx, and with it the epiglottis quite far 
 downward. During examination without anesthesia the child by spas- 
 modic laryngeal activity holds its breath for a considerable period. Then 
 when it takes a breath, it is a deep and violent inspiratory movement 
 which jerks the larynx downward, pulling the epiglottis, which is, at best, 
 "as slippery as an eel," away from the specular tip. In following this 
 elusive epiglottis downward the endoscopist is apt to insert the speculum 
 deeplv just at the moment when expiration takes place with a rising 
 larynx; and thus the speculum goes behind the cricoid, which, if lifted 
 strongly forward (upward in recumbent patient), will shut ofl" the 
 larvnx and the beginner will be apt to quit bewildered, possibly con- 
 demning the direct method as impractical ; or, by shutting the larynx by 
 his forward lifting of the cricoid, he may cause respiratory arrest and 
 then condemn the proceditre as dangerous. 
 
 In direct examination of the lar\-nx in children it is necessary to re- 
 member that the normal respiratory movements, which are automatic 
 under the control of the respiratory center in the medulla, are totally 
 obliterated as long as spasm of the larynx lasts. Hence, we note in 
 children examined without anesthesia, that the glottis mav remain closed 
 for a large portion of a minute's time. In children wearing a tracheo- 
 tomic cannula, and hence not needing air through the larynx, the spasm 
 may contintie over a minute or more. In fact, it seems to the operator 
 who is waiting for it to open, to continue indefinitely. 
 
 Position. The recumbent position, as stated in a former chapter, 
 is the only satisfactory one for an infant or small child, and the author 
 prefers it for all patients under about sixteen years of age for the rea- 
 sons given. In dyspneic cases over-extension of the head must be espe- 
 ciall\- avoided because the traction on the trachea lengthening the trachea 
 necessarily narrows it, partly by the elongation and partly bv the sec- 
 ondary compressions induced. Moreover, e.xcessive extension is un- 
 necessar}- and if roughly applied can endanger the spine. It also makes 
 laryngeal exposure more difficult in children. Only moderate extension 
 IS necessary. 
 
 Endoscopic appearances of the child's laryn.v. The epiglottis of 
 children, when seen with the direct laryngoscope without anesthesia, is 
 very much more of a reddish pink with less of the vellow tinge of the 
 epiglottis of the adult, especially the adult epiglottis as seen by 
 the mirror or ( after cocainization » by the direct method. 
 The reason for this color is, probably, the engorgement of the ves-
 
 DIRECT LARYNGOSCOPY. 129 
 
 sels. Xotwithstanding the reddishness due to engorgement, indivi- 
 dual vessels are much less noticeahle than in the adult, part of the dif- 
 ference being anatomic and part being due, probably, to the reflex en- 
 gorgement during examination. 
 
 The size and especially the shape of the child's epiglottis vary very 
 extensively. .\s the larynx is higher, depressing (elevating in the recum- 
 bent patient I the tongue strongly will sometimes cause it to project up- 
 ward in full view ( Fig. 1. Plate II ). Often it retreats (|U!ckly and looks 
 more like Fig. !)."). It is usually more curved laterally than in the adult 
 and the lateral margins may curl backward until they meet forming a cyl- 
 inder. 
 
 In children the first view that one gets of the larynx is often 
 similar to A, Fig. 94, where the epiglottis is seen curled up and below it 
 
 Fu;. g.}. — Direct larynyoscopic views in chiUlren. Recumlienl position. A. 
 Larynx expo.secl by elevation with the spatular tip in the glossoepiglottic fossa, 
 anterior to the tonKuc. The curled epi.clottis hides all hut the two arytenoid em- 
 inences and the glottis is spasmodically closed. B. Same position glottis open. 
 C. Congenital laryngeal web in a child simulating a neoplasm when glottis is spas- 
 modically dosed. D. Same patient, deep inspiration. 
 
 arc seen the arytenoid eminences, .\othing can be seen of the cords 
 because the larynx is in a state of spasm. The normal infantile epiglottis 
 will ctirl up fully as much as seen in this drawing. Stronger traction 
 upward on ilie base of the tongue will often expose the aryepiglottic 
 folds continuous v, ith the arytenoid eminence posteriorly and with the 
 edge of the epiglottis anteriorly (!>, Mg. 91). Under these circum- 
 stances, also, the cords may not be seen because they are covered by the 
 spasmodic ckjsure of the n]>per orifice of the larynx especialK' the ven 
 tricular band. .\t tiie next inspiration, liowe\er, the cords will sejiarate 
 and a good view down the trachea can often be obtained in this way, 
 elevating the larynx with tiie spatuLar end in the glossoejjiglottic fossa 
 anterior to the epiglottis. .As a rule, however, this examination is not 
 so satisfactory, and it is Ijctter to proceed at once, as in the adult, after 
 identifying the epiglottis, as at .\, iMg. 9."i. to insert the laryngoscope 
 sulliciently deeper to go posterior to the e]iiglotlis and lift it I in the re-
 
 ]30 DIRKCT LARYNCOSCOPV. 
 
 cumbent position ) strongly as if to suspend the child by the hyoid bone, 
 using only the tip of the spatular end on the posterior surface of the 
 epiglottis. If the epiglottis slip away, the speculum must be inserted 
 slightly deeper, but onlv enough to catch the epiglottis, and great care 
 should be taken not to insert too deeply, as in that case the mouth of the 
 esophagus will be entered and no amount of lifting with the tip will 
 expose the larvnx, as before explained. \Mien properly exposed the 
 child's larynx will look ver\- much elongated antero-posteriorly and the 
 arytenoid eminences will project upward and outward like the arms of a 
 thick ^'. From the top of the arms of the \', the aryepigluttic folds 
 extend forward. The cords are very much deeper down and are only 
 visible on inspiration. (C. Fig. U-") which also shows subglottic papil- 
 iomata. ) If the larynx is lifted away from the posterior jiharyngeal 
 
 Fig. 95. — -Direct laryngoscopic views in children. A. Epiglottis. B. Gluttis on 
 inspiration, prevented from a wide inspiratory excursion by normal spasm at the 
 presence of the instrument in an examination without anesthesia. A few moments 
 later it opened widely, and subglottic papillomata are visible as shown at C. 
 D. Indrawing of the upper laryngeal aperture in a moderate case of congenital 
 laryngeal stridor, in an iufnnt of 11 numths. 
 
 wall the \ may become a thick-based ^". This flaring shape of the up- 
 per part of the posterior commissure is best understood by contrasting 
 it with the incurved laryngeal aperture seen in congenital laryngeal 
 stridor. (D, Fig. !l.") ). Plate 11 gives excellent views of the child's larynx. 
 Siipraglottic tracheoscopy and subglottic laryngoscopy in children. 
 Ordinarily the subglottic region can be seen well enough in children by 
 the direct laryngoscopic method described in this chapter. If, however, 
 more thorough study is desired, an excellent way to do it without pass- 
 ing a bronchoscope into the trachea, as for instance in a case in which 
 there is already slight subglottic edema that bronchoscopy wotild ag- 
 gravate, is by what the author has called "supraglottic tracheoscopy" 
 (Fig. 9(5). A short esoj^hagoscope. a tracheoscope, or a bronchoscope 
 with the distal end not slanted is selected of a size too large to go
 
 niKKCT LARYNGOSCOPY. 131 
 
 through the glottis. W lien the mouth of such a tuhe is insertetl in the 
 upper orifice of the larynx (heing introduced llirough the laryngoscope 
 precisely as if doing a hronchoscopy ) it will hold the \()cal cords, ex- 
 posing to view the entire length of the trachea, the vocal cords showing 
 slightly at the edge of the endoscopic incture. (Fig. in;). It is neces- 
 sary to make slight pressm-e on the tracheoscope, which must be too 
 large to go through. This was discovered in one of the atUhor's earliest 
 cases of foreign liodv. before he had [lerfected his equipment, auil the 
 only instrument available in a distant city was a short traeheoscojje of 
 8 mm. internal diameter. .\ safety-pin was thus removed with a hook 
 from tlie trachea of a twehe montlis old infant i I^)ib. 5iil). 'Po realize 
 the mechanism of sujiraglottic tracheoscopy it is necessary to understand 
 
 Fig. 96. — Endoscopic image ot)tained by supraglottic tracheoscopy. A tracheo- 
 scope or esophagoscope or bronchoscope whose distal end is not slanted and whose 
 diameter is too great to go through the glottis of the child is inserted in the upper 
 orifice of the larynx which is thus propped open. The widely spread cords arc 
 shown at the sides. This patient was suspected of having subglottic hypertrophy 
 but on tracheoscopy was found to have a thymic compression stenosis. A lateral 
 thymic comi)ression as lierc shown is exceedingly rare. Usually this form of com- 
 pression is anteroposterior. 
 
 the usually overlooked dejilli of the larynx above the cords. It is 
 into this funnel that the iube-ni"Ulli is inserted. Supraglottic traclieos- 
 copy could be used for the cauterization of subglottic hypertrophies 
 but direct laryngoscoijy, as elsewhere explained, gives more lateral rt)oni 
 in which to work. Supraglottic tracheoscopy is useful in ihj remo\al of 
 long-pedii-led ^u!it;lottic growths that Hop ;ibo\e and below the rmia 
 glcittidis. 
 
 Iiu/:r,-rt Idryiiqoscopy '^■Ith tlic Hays ph(iryii</(}scof'C.* The Mays 
 pharyngosco|ic is an instrument which can be used either for the ex- 
 amination of the naso-pharynx or the larynx. It is composed of a small 
 telescope (similar to the cystoscope) which is enclosed in a flat metal 
 
 •Written by l-IaioUl M. Hays, M. D. For further detnils the reader Is re- 
 ferred to the intfrestiiig articles of Hays, I3ecl<, Krledcnwald and others.
 
 132 DIRECT LARYXGOSCOPY. 
 
 sheath, in which run wires which connect with small electric hulbs situ- 
 ated at the distal end on either side of the prismatic lens. At right angles 
 to this tlat piece is a handle which connects with the rheostat. 
 
 The instrument is used like a tongue depressor and for the examina- 
 tion of the larynx may be employed in one of three ways. 
 
 (1) The distal end is inserted behind the soft palate with the lens 
 turned up. The patient is then told to close the teeth and lips over the 
 instrument and relax the muscles of the throat. ( )ne thus obtains a view 
 of the naso-pharynx. If the lens is then turned either to the right or left 
 through a half circle a view of the larynx can be obtained. 
 
 (2) The lens is turned down instead of up and the instrument in- 
 serted until the distal end almost touches the pharyngeal wall. The mouth 
 is then closed as in the first instance. 
 
 (3) In many instances a larger and better view of the larynx can 
 be obtained if the tongue is held by the examiner in the same way as if 
 the laryngeal mirror was going to be used. The instrument is then dipped 
 down towards the larynx until it is just over and behind the epiglottis. 
 An excellent view of the larynx may be obtained in this way. 
 
 Operations on the larynx can often be performed by the indirect 
 method, using the pharyngoscope instead of the mirror. The chief ad- 
 vantage of this method is that the operator does not have to work at right 
 angles to his line of vision. In oiJerating in this way the pharyngoscope 
 should be inserted laterally as in method three, and the operative instru- 
 ments from the opposite side of the mouth. [As the instrument is of iixed 
 focus, the observer should wear his reading glasses. — Author.)
 
 CHAPTER VIII. 
 
 Suspension Laryngoscopy. 
 
 A HISl'ORICAI,. 
 
 Over the portals of the Anatomical Institute at Freiburg in L'.reisgau 
 is written in golden letters: "^lortui vivos docent" — the dead are the 
 teachers of the living. This expression may likewise be applied to sus- 
 pension-laryngoscopy. which originated in the Freiburg .\natomical In- 
 stitute as a result of observations on the cadaver. 
 
 In the winter ni T.Mi!i-l(i I had my artist there produce the picture 
 obtained by direct laryngoscojjy upon the cadaver. I utilized the old 
 broad Kirstein spatula on an electric handle and introduced it with the 
 head pendant. .\s 1 did not have the time to hold the instrument until 
 the artist had com])leted his picture I improvised a fixation-apparatus 
 with several iron rods which were attached to the dissecting table. 1 
 attached the handle to the rods. Thus the head of the cadaver hung 
 suspended from the mouth-siiatula. The mouth was forced widely 
 oi)en. The teetii of the upper jaw were missing. I had a comprehensive 
 view into the depths and was astonished at the excellent birds-eye view 
 of the entire topographical relationship of the mouth and pharyngeal 
 cavit}', as well as of the larynx obtained at one glance. I was even able 
 to see into the hypo])harynx and, as the larjMix was raised from the 
 vertebral column, through the eso])hageal opening into the esophagus. 
 The situation was about as discernible as in I-'ig. !•?. Laterally from the 
 broad tongue-spatula the tongue arches. We recognize the posterior 
 pharyngeal wall from the uvula to the esophageal opening in its entire 
 length and breadth. In tlie depth the large cornua of the hyoid bone 
 project on the right and left. The posterior surface of the larynx is 
 visible in its entire area. Of the laryngeal cavity the posterior surface is 
 particularly well seen. Only the anterior sections of the vocal cords are 
 invisible. 
 
 •K.speciaUy written hy Prof. Killiaii fur- tlii.^ bunk. Tianslati'd by J. A. 
 Hageman. M. D.
 
 134 
 
 SUSPENSION LARVXCOSCOPY. 
 
 This experience set me to thinking. It showed me how one must 
 proceed to obtain a broad entry to the depths of the neck. It pointed 
 a way to the fulfilhnent of a wish I had long liarbored — to find a broad 
 entrance to the laryngeal cavity in order to operate there as gynecolo- 
 gists do in their field. LUit there was still a long journey to the suc- 
 cessful consummation of the procedure upon the living. At first I deemed 
 profound narcosis absolutely essential in order to relax the parts as 
 thoroughly as in the cadaver. As sufficient opportunity to narcotize pa- 
 tients for such purpose was not afforded. I made no progress. During 
 
 i-ig- 97- 
 
 the following winter I therefore proceeded to practice upon two clinic 
 patients using only cocaine. These experiments gave me opportunity to 
 construct a fitting instrumentarium. thereby consuming much time. Not 
 until the fall of fStf] had I made sufficient progress to enable me to 
 issue a statement at the International Laryngological Congress in I'.erlin 
 concerning suspension-laryngoscopy. 
 
 The time was very opportune for the further elaboration of the 
 method because of my appointment as Director of the Berlin Lar}-ngo- 
 logical Polyclinic. There I had sufficient material at my disposal to 
 elaborate the new procedure jM-actically in all its miiuitiae. New instru-
 
 SrSl'EN'SIOX LAKVNGOSCOl'Y. 135 
 
 meiils were constantly constructed, altered or abandoned. Now I have 
 nnally reached the point where I can regard the method as matured. 
 
 Since then I have spoken and written about suspension-laryngoscopy. 
 and have often demonstrated it. The procedure has been used by my 
 pupils, Alhrecht and Hoelscher. and also by Brieger and Seift'ert, Wolff, 
 Hinsberg and Kleestadt. Gerbcr and Henke, Lautenschlaeger, Storat, 
 Kahler. Katzenstein, Hopmann and Froning, Chiari. Steiner, Pollat- 
 scheck. Simoleki, Davis and Howarth. Freudenthal, Iglauer. Through 
 their collaboration the method has attained great clinical importance. 
 
 B — I X SIR I ■ M !■: X TS. 
 
 \\'hoever desires to familiarize himself with suspension-laryngoscopy 
 must primarily know the instrumentarium thoroughly. I therefore be- 
 gin with a description of them. 
 
 ] — THli OPi:u.\Tl.\G T.ABLIv. 
 
 As this method is frecjuenlly used, it is desirable to have an oper- 
 ating table ijarticnlarly suited to this purpose. It should have qualities 
 which make it most practical for the execution of direct examination, 
 and if possible, should be convenient for the numerous operations nowa- 
 days ]jcrformed in laryngology and rliinolog\-. 1 have, therefore, con- 
 structed a new tabic.* 
 
 It seems desirable that the operator should be able to adjust the 
 table itself or at least to change its position. For this reason all cranks 
 were aflixed to the head-end of the table. I have always found it very 
 uncomfortable to sit on a stool or kneel and assume a stooped position 
 while using the ordinary operating-table. It is verv exhausting. Direct 
 examination should be made while sitting on a chair, or while standing. 
 Therefore the operating-table should be so constructed that it can be 
 sufficiently elevated by means of a screw. Kahler has already built such 
 a table for the X'ienna Laryngological Clinic. Mine is somewhat simpler; 
 by means of a screw one can elevate it as much as desired. Besides, it 
 is so arranged that one can securely attach the suspension-appliance. 1 
 have likewise attached a separate supporting-apparatus for the head. 
 Further jiarticulars may be gleaned from Figs. i'S, 9!) and loii. Fig. 98 
 shows tiie table in ordinary position, Fig. !i!t in high ])Osition. In Fig. 
 100 one sees it from the head-end together with the various screws by 
 means of which the changes of position are made. I need not dilate 
 ui)on the minutiae of construction. These are based upon simple prin- 
 ciples and are evident in practical u.se. 
 
 •All the In.struments here minutely Jesciibed may be obtiilncfl friim the liims 
 Windier, in P.erlin. and Fi.^cher. in Freibui's; I. Dr.
 
 136 
 
 SUSPENSION LARYNGOSCOPY. 
 
 2 — THE GALLOWS. 
 
 The gallows is intended to provide a suitable suspension-point. I 
 have used it as it stands now, for two years without altering it in any 
 way. It essentially consists of a column (Fig. G) bearing a horizontal 
 arm (a). The arm extends to the middle of the operating-table. It 
 may be fixed higher or lower, forward or backward. The elevation is 
 chiefly adjusted by transposing the column. In addition the horizontal 
 arm may be changed 20 cm. within the column. The forward and back- 
 
 FiS. g8. 
 
 ward motion of the entire contrivance is accom])lished by means of a 
 screw (b) (compare Figs. 101 and 102). The gallows is screwed to the 
 operating-table on the right in the maimer shown in Figs. 99 and 116. 
 
 '^ — THE SUSPENSION- 1 1 01 IK. 
 
 The suspension-hook was formerly more sim])le in form. It con- 
 sisted of a straight rod which was curved at the ujtper end in the form 
 of a hook. (Fig. 103 and 104). Compare my essay in "Archiv fi'tr 
 Laryngologie," Vol. 3G, 1912. According to Albrecht's investigations, 
 however, it was found necessary to put a joint in the rod (compare Fig. 
 104a). Within this joint a backward turning of the hook takes place 
 about a horizontal axis (compare Fig. 106). This movement is accom-
 
 SUSPENSION LAKYNC.OSCOl'Y. 
 
 137 
 
 plished when one turns the thumb-screw clockwise. In this manner the 
 hook may he turned almost to a horizontal ])Osition. The mechanism is 
 based upon the principle of the endless screw. The portion helow 
 the joint shows several peculiarities. The rectangular caxitv (e) con- 
 tains the screw. (Fig. lO.'jf). The tongue-spatulas are attached to the 
 pegs (g). The screw (h) holds the epiglottis-spatula. .\n attachment 
 which holds the mouth open, a sort of mouth-gag also is supplementary 
 to the suspension-hook (compare Fig. 10.5). It is provided with a tooth- 
 plate (k) which rests against the upper incisors. This tooth-plate is so 
 
 arranged, (i.autcnschlacger ). that it may be extended or shortened. This 
 is accomplished by means of the screw (h). The screw-end of the 
 liandle is inserted into the part (d) of the hook-si)atula, and is securely 
 fixed there by means of the screw (f) as shcjwn in h'ig. ]0(). By turn- 
 ing the screw (f) the handle (!) may be variously placed. In this man- 
 ner the patient's mouth may be opened as wide as seems desirable. 
 
 4 — Till- TONC.ui:-sp.\rri..\. 
 
 The tongue-spatula has in the course of lime undergniie many modi- 
 fications, but we now possess a model which meets all demands. In 
 its construction 1 have adopted the alterations wliich Albrecht proposed.
 
 138 
 
 SUSPEXSIOX LARVNGOSCOPV. 
 
 Figs. 100, loi, 102, 104, 105, 106, 107, loS, 100. no.
 
 SUSPENSION LARYNGOSCOPY. 
 
 139 
 
 Figs. Ill to 1 1 6.
 
 140 
 
 SUSPENSION LARYNGOSCOPY. 
 
 Of late a series of details were added. The tongue-spatula must be a 
 simple instrument which has a peculiarly formed handle for attachment 
 to the suspension-hook, (m) Fig. 107 ; the upper surface which is di- 
 rected toward the tongue is rough (Fig. 107n), so that the spatula will 
 not slip off. Its anterior end is heart-shaped after the model of the 
 Reichert hook for raising the epiglottis (Fig. ll'J). On the free sur- 
 face of the tongue-spatula one observes a gutter (o). Into this gutter 
 
 is placed a second smaller spatula, by means of which the epiglottis is 
 raised, the epiglottis-spatula (p) Fig. 108. It is inserted through a 
 groove. Fig. 108. If the patient's tongue wells up to the right and left 
 of the spatula, it hinders vision into the depths of the neck. I there- 
 fore have recently had two movable lateral wings attached to the tongue- 
 spatula (r) (Fig. 109 and Fig. 110). These wings may be turned by 
 means of a key (Fig. 109r) and (Fig. 109 and Fig. 110) fixed in any
 
 SUSPENSION LARYNGOSCOPY. 
 
 141 
 
 position. The key (s) is removed after the fi.xation of the plates. In 
 Fig. 108 we see the tongue-spatula in connection with the epiglottis- 
 spatula. Tn Fig. Ill the tongue-spatula is attached to the suspension- 
 hook. In J'"ig. 112 we see the tongue-spatula on the suspension-hook 
 with the epiglottis-spatula as seen from the side. Fig. 113 shows a 
 froiU \iew of the same. 
 
 5 TH K COUNTICR-PRESSOR. 
 
 In order to hring the anterior portions of the larynx within the range 
 of \ision it often hccomes necessary to exert pressure externally against 
 
 Fi.?. 1 1". 
 
 the cricoid cartilage. This requires the aid of an assistant. Tn order to 
 obviate this, .Mhrecht has attached the Briinings counter-pressor to his 
 instrument. I have constructed a counter-pressor upon new principles 
 (Fig. III). It consists of two parts, t and t, which can be telescoped 
 into each other, and may thus be lengthened or shortened. It may also 
 be turned ui)on a horizontal axis at u. It is attached to the portion of 
 the suspension-hook directly over the screw (Fig llo). After the sus- 
 pension-hook is connected with all its supplementary instruments it is 
 suspended from the gallows as shown in Fig. llC In this position it is 
 used during suspcnsion-laryngoscopy. Whoever desires to make the 
 examination successfully must first familiarize himself with the minutiae 
 of my construction. Only in this manner is it possible to utilize all its 
 advantages. The whole arrangement may apjicar somewhat complicated.
 
 142 Sl'SPEXSION LARYNGOSCOPY. 
 
 These com])Iications, however, are necessary to ensure ihe best condi- 
 tions for the prompt engagement of the larynx. 
 
 (i — THE ILLUXIIN.^TION. 
 
 In laryngoscopical work the month ami pharyngeal ca\ity are il- 
 luminated in the usual manner. (Jne ma_\- use the head-mirror in con- 
 nection with a good electric or gas lamp. I usually use the Kirstein 
 head-lamp (Fig. 117). For demonstration purposes it is fouinl very 
 satisfactory to vise a diminutive electric lamp whose light is concentrated 
 by means of a lens attaching the light to the tooth-plate of the suspen- 
 sion-hook by means of a clamp. (Compare Figs. 122 and 12.'5, Plate IV). 
 
 7— -Tll!-; PERFORMING OF SUSPKNSIOX-L.VRVNCOSCOPV. 
 
 Not every patient is adapted for the performance of suspension- 
 laryngoscopy. All patients presenting difficulties during the use of the 
 direct method are difficult to examine in the herein described manner, 
 and it may prove impossible to do so at all. Generally speaking the num- 
 ber of such cases is small. In children one practically never meets with 
 difficulties. In order to ascertain in advance if the patient can be com- 
 fortably examined, it is advisable to attem])t a direct examination of the 
 larynx with the simple Kirstein spatula, lly this means one recognizes 
 how far the tongue may be sup[>ressed and the larynx engaged. 
 
 PRi;r.\R.\Tiox 01- Tin-: p.\tient. 
 
 Adults who are adaptable for the direct examination can be exam- 
 ined by means of suspension-laryngoscopy, using cocaine .solely, although 
 as a rule it is wise to administer a morphine injection ( O.Ol-O.fll.-)) half 
 an hour previously. 
 
 If one contemplates doing an operation which may C(jnsnme more 
 time and may possibly cause pain, it is better to make use of the mor- 
 phine-scopolamine narcosis. Scopolamine is lately furnished by the firm 
 HofTmann-I,a Roche & Co., in Crenzach (1 laden t in permanent form 
 under the name "sko])olamine haltbar, Roche." Three decimilligrams are 
 hermetically enclosed in a small glass ampoule. This is the most suitable 
 dose for our pur])0ses. 
 
 The best [irocedure is to administer to the patient two hours lie- 
 fore the suspension-laryngoscopy 0.01 gm. morphine and .(U)i)'.> dcmgm. 
 scopolamine hy])odermically. (Jne hour later the same (iuantit\- of both 
 substances is again administered. The patient must recline in a quiet 
 place, so that he will go to sleep. In most cases the numbing is only in- 
 complete. I'liit the patient is in such condition that he undergoes the ex-
 
 SrSPlCNSION I.AKVNC.OSCOl'Y. 
 
 143 
 
 amination witliout resistance and also bears it longer. It is necessary, too, 
 to pencil (he larynx with cocaine before using the s])atula. The reflex- 
 irritability of the pharyngeal and laryngeal mucous membrane is not 
 entirely eliminated by the morphine and scopolamine. 
 
 Children and young persons must not receive any nmrphine-scopo- 
 lamine. In childhood it is best to use ether or chloroform narcosis or a 
 mixture of both. It is i>referable to use the llraun insufflation-apparatus, 
 because wi'h it one more rapidly attains a sufficiently profound narcosis, 
 and above all, because the narcosis can easily be maintained sufficiently 
 profound during the manipulation in the neck. (Fig. 11!)). To hold, a 
 mask before the face from time to time during the examination causes 
 
 1 _1^ 
 
 Fig. liS 
 
 too much interrnjition. Uul when one forces llu' clhcr nv chlorolunn in- 
 to the de])ths with the insufflator as nuich will be inhaled as is re(|uired 
 to maintain an ecjuable, deep narcosis. 
 
 In children, too, it is to be recommended to pencil ihe larynx with 
 cocaine, lly cocainizing, one avoids the reflex interference with breath- 
 ing which occurs in some cases when one touches the interior of the 
 larynx with an instrument. I generallx' use the laryngeal mirror and 
 the Kirstein head-lam]) when ])enciling llie larynx in a<hills and chil- 
 dren. If til'.' larynx cannot readily be approached the lower jaw is 
 pidlcd forward or the Reiclurt book is inserted at the lingual base and 
 the base of the tongue and ihe larynx are pulled forward by this means. 
 (Fig. 110).
 
 144 
 
 SUSPENSION LARYNGOSCOPY. 
 
 THE PREPARATION OF THE SUSPENSION-HOOK. 
 
 Preceding the introduction a tongue-spatula of suitable length must 
 be selected — Kahler determines the length by means of a graduated Kir- 
 stein spatula (Fig. 1"'0 ) — and connected with the suspension-hook. The 
 handle with the tooth-plate is inserted in such manner that the mouth 
 is forced open only slightly. The counter-pressor is folded upward. In 
 addition it is necessary to move the hook so far backwards by means of 
 the thumb-screw that its end comes to lie perpendicularly above the end 
 of the tongue-spatula. In this form the instrument is introduced. 
 
 Fig. 1 19. 
 
 %nai6r. 
 
 w 
 
 Fig. 120. 
 
 Before introducing the tongue-spatula the patient must be put in 
 the proper position. The body is drawn so far upward that the head 
 extends freely above the edge of the operating-table and can readily 
 be lowered. At the same time an assistant holds the head in a slightly 
 lowered position. 
 
 INTRODUCTION OF THE TONGUE-SPATULA. 
 
 Formerly I always used a special mouth-gag and had the tongue 
 held with a forceps. Lately I avoid both whenever possible. As Seifert 
 has demonstrated the mouth-gag or tongue-forceps is not essential. It 
 is, however, advisable when introducing the spatula to some depth to 
 have the tip of the tongue held, so that the spatula may not push the 
 tongue too tar into the depths.
 
 SUSPENSION LARYNGOSCOPY. 
 
 145 
 
 Under illumination with the Kirstein head-lamp the spatula is in- 
 troduced against the posterior jiharyngeal wall and then downward along 
 this wall between epiglottis and base of tongue. The base of the tongue 
 is forced upward as much as possible, and the gallows is now so installed 
 that the hook can be suspended from it. If one has been successful in 
 this, the assistant gradually releases the patient's head, so that its whole 
 weight presses upon the tongue-spatula. 
 
 In most cases the interior of the larynx does not yet become visible 
 in this position, the ipigloltis covers it almost entirely. To elevate this 
 the ejiiglottis-spatula is rei|uire(l. 
 
 As already slated abo\e. the c[)iglottis-spatula is inserted through 
 the groove in the tonguc-si)alula. and jiushcd iiUo the depths under the 
 epiglottis as far as possible. Then one elevates the epiglottis with it
 
 146 SUSPEXPIOX LARYNGOSCOPY. 
 
 and secures the epiglottis-spatula with the screw. After this procedure the 
 ar\-tenoid region and the posterior laryngeal wall ordinarily come into 
 view. It now becomes essential to accomplish the finer adjustment, so that 
 the anterior portion of the larynx may also be seen. For this purpose we 
 turn the thumb-screw clockwise, so that the hook drops even lower. 
 Should this not prove sufficient one may press upon the cricoid cartilage 
 with a finger, or accomplish this ])ressure with the counter-pressor by 
 adjusting and fixing it at the proper spot. Now it is also time to re- 
 move the handle with the tooth-plate somewhat farther from the tongue- 
 spatula and thereby force the mouth open as wide as possible. This 
 is accomplished bv turning the large screw (f) (Fig. lOd). 
 
 If one has been successful in this manipulation the interior of the 
 pharyngeal cavity must, with good ilhimination, lie in full view. The 
 patient is then in a position as shown in Fig. 1>'1. The head hangs free- 
 ly suspended from the tongue-spatula : the mouth is held open by the 
 handle with the tooth-plate. The portion of the hook bearing the screw 
 extends approximately in a perpendicular position. The hook itself is 
 turned sharply backward and so is suspended from the gallows. One 
 sees the larynx as in Figs. 123 and 123, Plate IV. 
 
 D — DEM0NSTR.\TI0X I.X SUSPEXSK.IX L.\KYXGOSC()PY. 
 
 The new method is particularly adapted for demonstration. If 
 the pharynx and larynx are engaged the demonstrator has nothing to do 
 but make the necessary explanations. The pupil readily grasps the sub- 
 ject because he sees the parts directlv before him. As above mentioned, 
 it is best for such demonstrations to use a miniature electric lamp at- 
 tached to the toothplate of the instrument. When the lar_\nx is engaged 
 during suspension laryngoscopy it is very easy to manipulate its interior. 
 One can demonstrate this to the pupil by putting a probe in his hand 
 and having him touch designated points. 
 
 Minor operations, for instance the removal of a polyp, can be dem- 
 onstrated without much trouble. If the ])atient is under skopolamine- 
 morphine "twilight sleep," the demonstration may be made, without 
 hesitation to a very great number of physicians and students. 
 
 E — CLINIC. \I. KXPKRIKNCKS WITH SUSPEXSIOX-L.VRVXCOSCOPY. 
 
 Suspension-laryngoscopy has been successfullv applied in practice 
 both in diagnostic and therapeutic respect by my jjupils and b\- me as 
 well as by a list of authors. It is used diagnostically especially in child- 
 hood and particularly in all those cases where we are comjjelled to re- 
 sort to direct examinations. Its execution is so simple that I believe 
 it will soon replace direct laryngoscopy. We often have occasion to make
 
 SrSI'K.NSIIlX l..\U>\('.0SCO['Y. 
 
 147 
 
 minute examination nnder narcosis in voc-ai and resjiiratory distnrliances 
 in oliildrcn. One mnst determine if there exist a simple iciite catarrh, 
 a sub-glottic swelling, a croupous or di[)iulieritic process with forma- 
 tion of pseudo-membrane, a jierichondritis. or if there be a foreign body 
 present whether there be a chronic laryngitis, formation of nodules on 
 the vocal cords, papillomata, tuberculosis or syphilis. ICven cases of 
 
 dit'licult decanulement or congenital changes in the lar>n\ may be con- 
 veniently examined in su.spension. 1 sliould like even at this stage, to 
 recommend this procedure as a preparatory step for bronchoscopy and 
 esophago.seopy in small children. With suspension-laryngoscopy one 
 engages the larynx and then inserts the bronchoscopic or esophagoscopic 
 tube into the deiiths. Narcosis can be maintained without special dan- 
 ger. ScilTert has shown that artificial respiration may be accomplished
 
 148 
 
 SUSPENSION LAKVNGOSCOPY. 
 
 with the horizontal suspension-hook. One must never neglect to co- 
 cainize the larynx before inserting the instruments in order to eliminate 
 the vagus-reflexes emanating from the laryngeal mucous membrane. 
 With the introduction of a cold instrument into the uncocainized larynx 
 temporary discontinuance of respiration may very readily occur. 
 
 THKR.'VPECTIC .\PPLICATIOX OF Sl'SPENSION-LARVNGOSCOPV IN CHILDHOOD. 
 
 a. Foreign Bodies. 
 
 Davis removed a safety-])in from the pliaryn.x of an eleven-months- 
 old child under suspension-laryngoscopy. My pupil, ^^'eingaertner, re- 
 centlv succeeded in extracting a piece of bone which was lodged partlv in 
 
 Fig. 125. 
 
 the phar\nx and partly in the entrance to the lar\nx of a child one and 
 one-half years old. Seiffert reports the removal of a flat bone from the 
 sub-glottic space in a child of five years. Iglauer removed a piece of 
 safety-pin which had been lodged in the larynx of a child for five months. 
 All observers state that the location and extraction of foreign bodies 
 offer no special difficulties. The condition is probably the same with 
 deep-seated foreign bodies whether lodged in the esophagus or in the 
 larynx or bronchus. A tube is projected into these organs — a very simple 
 procedure during suspension-laryngoscopy. By means of suspension- 
 laryngoscopy I succeeded in locating in and e.xtracting from the right 
 bronchus a metallic capsule. In the same manner I removed a nail 
 which had been lodged for a year in the left bronchus of a two-year-old 
 child. Both cases impressed upon mc that this sort of bronchoscopy is 
 easier and better.
 
 SUSPENSION I.AKYXC.OSCOPY. 
 
 149 
 
 l.AKVNCKAl, I'AI'IIJ.OMATA IN CIIII.DRKN. 
 
 In my clinic we were able to gather extensive data bearing on this 
 affection and its treatment. Albrecht has frequently and minutely re- 
 ported on it. The new method not only permits a certain diagnosis but 
 also a radical removal. Even if the larynx is entirely filled with papil- 
 lomata, one can remove everything at one sitting, if the children are 
 already dyspnoeic, suspension-laryngoscopy may still be carried out. 
 Obviously the tracheotomy instruments must be in readiness. If one 
 has succeeded in api)lying the suspension-hook one need no longer fear 
 
 m= 
 
 Fig. 126. 
 
 Fi^. 127. 
 
 asphyxiation, for one caii w ithout furtlu-r ado insert a bronclioscopic tulie 
 through the larynx and wait until respiration is again in progress. The 
 larynx is always readily accessible in suspension. Obviously one must 
 use narcosis. There is no conlra-indication to repeat such sittings. As 
 the i>apillomata readily recur, many cases re(|uire numerous sittings, 
 sometimes even a long series of such. Sometimes one succeeds by means 
 of internal remedies, such as i(>(lide of potassium or arsenic, to prevent 
 recurrences. Penciling with l«» ])er cent salicyl-alcohol has also been 
 recommended. 'i"he mesolhoriuni-treatment as a remedy against recur-
 
 150 
 
 SUSPENSION LARYNGOSCOPY. 
 
 -_-:#?» 
 
 Fie. 128.
 
 SL'SPENSIO.V LARYNGOSCOPY. 151 
 
 rences appears to me to be one of the most promising. However, we 
 have not yet gathered any particular experience. Albrecht has succeed- 
 ed in removing papillomata in a large number of children. Others, too, 
 have reported favorably upon the application of suspension-laryngoscopy 
 to the removal of papillomata. as Wolff, Kleestadt. Mann and Katzen- 
 stein. Seiffert mentions a case in which tracheotomy was indicated but 
 in which it was possible, by removal of the papillomata, to avoid that 
 operation. Kahler has removed numerous papillomata from the hypo- 
 ])liarynx and eso])hageal entrance of a three and one-half year old chikl. 
 
 NODULKS Ol-" VOC.\L CORDS. 
 
 Xoduk's upon llie vocal cords of children arc not at all rare. They 
 are usually accompanied by a slight catarrh and cause a permanent 
 hoarseness. ( )ften we have to deal with children who suft'er from im- 
 perfect nasal respiration in consequence of hv|)ertrophy of the pharyn- 
 geal tonsils, turbinal swelling and septal deflections. Frequently one can 
 prove that the children have cried very much for a long period. 
 
 Most young patients do not permit intcrveiUions in their larynx. 
 One can therefore only work by the direct method under narcosis. Sus- 
 pension-laryngoscopy is particularly ada])ted for this, as has been em- 
 phasized by Seift'ert and b\ Katzenstein. M\- best results have likewise 
 been with this method. The nodules are removed with a small forceps 
 or a small guillotine. 
 
 In diphtheria, in s_\pbilis ami in tulierculosis in children, suspension- 
 laryngoscojn- is chiefly used merely for diagnostic purposes, although we 
 have already begun to make curettements and excisions in rare cases of 
 laryngeal tuberculosis. Difficult decanulement should more frequently 
 prompt us to undertake susjjension-laryngoscopy. As has been proved 
 one can thus readily obtain a clear view of the larynx. One can also as- 
 certain the conditions in the subglottic region and granulation- formation 
 over the canula. It may become necessary to insert a lube thrciui^h the 
 rima glottidis in order lo approach these granulations. I'.\en Seilfert 
 rejjorts a case with subglottic granulations. 
 
 TNTKKVICNTIONS IN Tl I !■: OKo-l'l I AUV N \ A.M) IN T 1 1 I'. i:S(il' M ACTS. 
 
 .\lbrecht. h'reudenthal .-nid 1 |H-rforme(l tonsdlectoniies in small chil- 
 dren imder narcosis by use of a broad tongue-spatula with the susjien- 
 sion-hook. When one works on the suspended head one sees the tonsils 
 reversed. Their up|)er pole appears to be below. (")ne must therefore 
 accordingly change the technique. Tt is very convenient that luniorrliage 
 causes no great trouble. The blood flows into the naso-phar\n.\ and cm 
 be drawn by suction from there through the nose.
 
 153 
 
 SUSPENSION LARYNGOSCOPY. 
 
 SUSPENSION-l.ARYNGOSCOPY IN ADULTS. 
 
 In the adult suspension-laryngoscopy is chiefly used in tuberculosis 
 of the larynx, especially when one contemplates curetting a diseased por- 
 tion. One will decide in favor of this method, especially in the cases of 
 advanced laryngeal tuberculosis, for it puts us in position to undertake 
 extensive work at one sitting, to curette, to nip off or even to make one 
 or two deep galvanic punctures. It is very important that phthisic pa- 
 tients who are to enter a sanitarium be relieved of the most pronounced 
 changes in the larynx. 
 
 Suspension-laryngoscopy can be carried out under local anaesthesia 
 in such cases following administration of one morphine injection. In or- 
 der to reduce the great reflex irritability of the tuberculous larynx, how- 
 
 Fig. 129. 
 ever, it is advisable in just such cases to make use of the skopolamin- 
 morphine "twilight sleep." We have never seen serious disadvantages 
 from it. On the other hand, narcosis does not seem to be especially w-ell 
 borne by some tuberculars. 
 
 When a tuberculous larynx has been engaged with the suspension- 
 hook, it is advisable to attach a glass shield to the gallows before be- 
 ginning the currettement so that tuberculous material may not be coughed 
 into one's face (compare Fig. 1?4). 
 
 For curettement I have had a reversible curette constructed (Fig. 
 125). The nipping off of infiltrations and granulations is done with the 
 ordinary double-curette for direct operations (compare Fig. 12G and 
 127). In cases of hemorrhage, clamps may he applied ( Fig. 128). 
 
 The galvano-caustic deep puncture may be executed with great se- 
 curity. An ordinary pointed cautery electrode which must be at least
 
 SUSPENSION LARYNGOSCOPY. 
 
 153 
 
 20 cm. in lenglli is used for this purixisc. 'i'heii tliu larynx is painted 
 with hydrogen peroxide and insulHated w ith \ ioform or anesthesin. 
 
 The subset|iient manii)iilation in the larynx must be under guidance 
 of the laryngeal mirror, .\ftcr maior incursions oedema mav readily 
 
 Fig. 130. 
 
 occur. For successfully combating such incidents we now have an ex- 
 cellent remedy in the hot-air-chest of .Albrccht which can be used again 
 the same day if necessary. (Fig. 12!)). Temperatures up to 110 degrees 
 Celcius can be aiiplied. 'i'be skin of the neck bears this dry heat very 
 well if the chest is well lined with asbestos-fibre. A strongly active hy- 
 peraemia results and the oeclemas are re-absorbed. The [iroccdure has 
 an anodyne effect. Of course the jiatient always complains of pain dur- 
 ing the first few days. This is caused not alone by the wounds in the 
 larynx, but also by the [jressure-elTcct of the lingual and lar\ngeal spat- 
 ulas. One also frequently observes temperature-elevations of minor or
 
 154. SUSPENSION LARYNGOSCOPY. 
 
 greater degree, which \ery readily occur from \arious causes in tuber- 
 cular patients. They soon subside. I prefer in the after-treatment, to 
 give iodine internally and peroxide of hydrogen locally. It is also ad- 
 vantageous to continue treating the cleansed wounds of the larynx with 
 lactic acid. 
 
 Obviously the result of such operative treatment depends upon the 
 state of the lungs and the general condition. Patients who can imme- 
 diately receive sanatorium treatment have good chances of cure if the 
 larynx be primarily aiTected. 
 
 By adopting radical measures in the larynx, tracheotomy has often 
 been obviated ( Holscher. Seiffert, Freudenthal >. Exposure of the tuber- 
 culous larynx to Roentgen-rays through the lumen has also been success- 
 fully accomplished in suspension-laryngoscop}- by Brieger and his pupil. 
 SeifYert. 
 
 In difficult cases of pol\ps of the \ocal cords, especially when the 
 polyps were located far anteriorly. Hoelscher and Steiner used suspen- 
 sion-laryngoscopy with the best results. E. Allayer has successfully re- 
 moved a carcinoma of the epiglottis under suspension-lar\-ngoscopy. It 
 has further been applied in scleroma, and even in hysterical aphonia. 
 
 A new field has arisen for it in mesothorium treatment of laryngeal- 
 carcinoma, about which I have recently made a report. I'.y means of 
 suspension-laryngoscopy not only can the small mesothoriuni-capsule be 
 applied lo the diseased spot introduced into the carcinoma under skopo- 
 iamine-morphine narcosis, but especially the sitting ma}- lie extended 
 sufficiently long. The patient may be left in suspension one hour, or 
 even one and one-half hours (probably even longer) without compunc- 
 tion (Fig. 1 :!()). 
 
 The mesothorium-capsule is provided with an aluminum-filter at- 
 tached to a cord and inserted into the lar\-nx with an ordinary claw- 
 force])s. Tlie instrument is secured with cords or clamps. Thus it will 
 remain quietly in position the entire time. During the first days there is 
 generally a light infiammatory reaction, but the improvement in the carci- 
 nomatous condition is soon apparent. 
 
 Suspension-laryngoscopy is peculiarh- adapted for examining and 
 treating operatively changes in the lower pharynx. True, one ordinarily 
 requires the additional help of a dilator to separate the larynx from the 
 spinal-column. Seiffert has reported more in detail regarding this as- 
 pect. I am not able, at this time, to state how extensively esophagoscopy 
 may be used in the adult in suspension. Apparently this procedure is of 
 great advantage in the removal of voluminous foreign bodies which are 
 wedged within range of the esophageal opening or immediately below it 
 (Brieger). Seiffert reports the removal of a coin from the hypopharynx 
 in two small children. He also was successful in the remoxal of a 
 lijioma from the hypoph.-uwnx during suspension.
 
 CHAPTER IX. 
 
 Introduction of the Bronchoscope. 
 
 The descrii)lion of the intruducticjn of the bronchoscope given in 
 some of the text-books woultl lead one to suppose that the procedure is 
 difficult and some books e\en go .so far as to say that, if after fifteen 
 minutes' trial the operator fails to introduce the instrument, a tracheot- 
 omy should be done for introduction. This state of affairs is almost in- 
 conceivable. Xo one should do lironchoscopy until he is able laryngos- 
 copically to exjjose the glottis with the left hand in not more than one 
 minute, and having learned this, it ought not to reijuire over one min- 
 ute more to introduce the bronclioscope into the trachea. The usual 
 time should be from fifteen to thirtv seccMids, depending on how long 
 the patient holds his breath (if not anesthetized), before taking a deep 
 inspiration. This length of time applies to infants as well as adults. 
 Whatever may be said of the difiiculties of bronchoscopy in infants, be- 
 cause of the smallness of the tube, it does not apply to the introduc- 
 tion of tlie bronchoscope by ihe auilun's method, because of the large 
 diameter of the author's laryngoscope for infants (12 mm.). This size 
 is [jossible because the laryngoscope by the author's method does not go 
 through the larynx — simply exposes its upper orifice to view. Once tiie 
 larynx is properly exposed there should be no diriicuity in introducing 
 even the 4 mm. tube. This is not mentioned jjoast fully nor as urging 
 hasty procedure: but rather to urge the necessity of abundant practice 
 in left-handed larxngoscopic exposure of the glottis. 
 
 INTRODUCTIO.N Ol' Till-; nUONCHOSCOPK, P.STIKNT SITTING. 
 
 I'or the nitroduclion of the bronchoscope in the sitting position, the 
 patient is usually locally anesthetized, the details for which are given 
 in a sc])arate cliai)ter. This position is advisable only in adults and only 
 for diagnosis. The position of operator, patient and assistants is pre-
 
 156 
 
 INTRODUCTION OF TEIK BRONCHOSCOPIC. 
 
 Fig. i,;i. — Schema illustrating oral bronchoscopy. The portion of the table 
 here shown under the head is, in actual work, dropped all the way down perpen- 
 dicularly. 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 broncho- 
 scope into the trachea. A, exposure of larynx. B, bronchoscope introduced. C, 
 slide removed. D, laryngoscope removed leaving bronchoscope alone in position. 
 The handle of the laryngoscope in C and D should be shown as rotated down to 
 the left as shown in Fig. 131a.
 
 INTRODUCTION OK THE BRONCHOSCOPE. 157 
 
 cisely the same as for direct laryngoscopy, as shown in Fig. 70 and de- 
 scribed in the adjacent text. After the larynx is exposed as there de- 
 scribed the introduction of the bronchoscope is precisely the same as in 
 the recumbent position, so that the one description of the procedure 
 will answer for both. The only difference is that the laryngeal image is 
 sagitally reversed. 
 
 INTRODUCTION OF THE BRONCHOSCOPE. RECUMBENT P,\TlENT. 
 
 The patient being in the Boyce ])Osition, as illustrated in Figs. 72 
 and 73. the glottis is exposed with the larj-ngoscope as shown in Fig. 
 
 z'\ 
 
 / 
 
 I 
 
 I 
 
 X 
 
 Fig. i.5la. — Before removing tlie slide the handle of llie laryngoscope should 
 be moved to the left from position Z to position X, rotating the laryngoscope 90 
 degrees on its tubular axis (Y). This movement clears the slide of all contact 
 Eo that it comes of? quickly. Used thus, the regular laryngoscope (Fig. 14) is 
 preferable to the side-slide or any form of open laryngoscope for the introduction 
 of bronchoscopes. 
 
 02. of which A, Fig. KM, is a reproduction. The same thing is shown 
 in Fig. I.'i3. 'i'he ojjcrator watches the larynx which is brilliantly illu- 
 minated by the light of the laryngoscope, while the first assistant hands 
 him the bronchoscope lighted with its own lamp. ( Xo warming or oil- 
 ing is necessary). The inslrunicnt is jiassed to the operator, properly 
 pointed toward the proximal end of the speculum so that llie operator 
 has but to reach up his right hand, grasp tlie bronchoscope and start it in, 
 catching the handle of the bronchoscope that is passed to him by the 
 assistant. The bronchoscope is inserted with the handle horizontally to 
 the right (Fig. l-M.'!). The eye is now transferred from the laryngo- 
 scope to the bronchoscope, and the bronchoscope is advanced until the
 
 ]58 
 
 INTRODUCTION OF THE BRONCHOSCOPE. 
 
 Fig. 132. — Exposure of the larynx of the recumlient patient. The operator is 
 lifting stronsly in the direction of the dart. 
 
 Vti': 133. — Insertion of the bronchoscope. Note direction of the trachea as in- 
 dicated by the bronchoscope. Note that the patient's head is held above the level 
 of tlie table. The assistant's left hand should be at the patient's month holding the 
 bite-block. This is removed and the assistant is on the wrong side of tlie table in 
 the ilhistration in order not to hide the position of the nperatnr's liands. Note the 
 handle of the bronchoscope is to the right.
 
 INTRODUCTION 01' THIC BKONCIIOSCOPK. 
 
 35D 
 
 inner end approaches (|uitc closely to llie jjlottis. If no anesthesia is 
 used, it is to be iireferred thai the distal end of the hronchoscope does 
 not touch tlie larynx lest an excess of spasm be excited, which would de- 
 lay the insertion. The handle of the bronchoscope is now moved slightly 
 to the right so as to throw the lip of the slanted end over into the median 
 line of the glottic chink, as will be understood from Fig. i:vl. This 
 
 Fic. 134. — Schema illustrating tlic introduction of the lironchoscope through the 
 glottis, recumbent patient. The handle, H, is always horizontally to the right. When 
 the glottis is first seen through the tube it should I)c centrally located as at K. At 
 the next inspiration the end, B, is moved horizontally to the left as shown by the 
 dart, M, until the glottis shows at the right edge of the field, C. This means that 
 the point of the lip, B, is at the mcilian line and it is then quickly (not violently) 
 pushed through into the trachea. At this same moment or the instant before, the 
 hyoid Ixine is given a (juick additional lift with the tip of tlie laryngoscope as shown 
 by the dart (Fig. 132) and at A in Fig. 13T. In the sitting patient everything is 
 the same except that the larvnceal image is reversed sa'.^illally .lud laterally. 
 
 sliding over should preferably be done at the moment that an inspira- 
 tion starts, so that the bronchoscope can be, at the same time, inserted 
 through the glottis. Herein lies a great advantage in the slanted end, 
 because it is very much easier to insinuate the li]) of the slanteil end 
 through the chink, than to insert the end of a tube which is scpiarelv 
 cut off. Care should be taken not to allow the lube to become hooked
 
 160 INTRODUCTIOX OF THE BRONCHOSCOPE. 
 
 over the arytenoid, though there is less Hkehhood of this in bronchos- 
 copy than there is in esophagoscopy. Ko great force should be used, 
 because if the bronchoscope does not go through readily either the tube 
 is too large in size or it is not correctly placed. On the other hand, the 
 tube does not normally go through without slight resistance, and the 
 laryngologist or rhinologist who has been trained to manipulative pro- 
 cedures, will very readily determine by his sense of touch the degree of 
 pressure necessary, and will not use a degree that will inflict trauma. 
 If the attempt is made to insert a 5 mm. tube through the glottis of an 
 infant under one year, there may be considerable resistance, and if so, 
 subglottic edma is quite likely to follow forcible introduction. On the 
 other hand, a -i mm. tube should go through with practically no resist- 
 ance, if properly placed. Once through the glottis (B, Fig. lol) the 
 direct laryngoscope should be removed as shown schematically at C, Fig. 
 ]31. The laryngoscope is turned sidewise just before removal (Fig. 131a) 
 so that the slide will not impinge on the upper teeth. Care must be taken 
 that the bronchoscope is not allowed to be cotighed out during the re- 
 moval of the speculum. The bronchoscope is most easily held in place 
 by the thumb of the left hand of the operator, while the thumb and finger 
 of the right hand are used to remove the slide. At the moment of in- 
 sertion of the bronchoscope through the glottis, an especially strong 
 upward lift with the beak of the spatula is usually necessan,' in order to 
 permit the brcinchoscope to be given also a forward t'.lt into the glottis 
 This prevents the bronchoscope reaching the posterior slant of the party 
 vi'all which would drift it off into the esophagus. The distance of in- 
 sertion of the bronchoscope into the trachea before removal of the 
 speculum is to be determined by experience. Usually if it has passed 
 two or three tracheal rings it will be found sufficiently deep. In case 
 a foreign body is expected to be located in the trachea, it is better not 
 to exceed this, lest the foreign body be dislodged and move downward. 
 For the same reason, the trachea should always be carefully in- 
 spected with the direct laryngoscope before attempting to insert the 
 bronchoscope, unless there is very serious dyspnea. It is very neces- 
 sary to be certain that the axis of the bronchoscope corresponds with 
 the axis of the trachea, before, as well as after, the bronchoscope is in- 
 serted, otherwise the distal end of the bronchoscojje will impinge on the 
 tracheal mucosa, inflicting trauma which is one of the factors in the 
 production of subglottic edema. In this connection it must be repeated 
 here that the direction of the trachea is not perpendicular to the long 
 axis of the body, but that it follows the thoracic spine backward as well 
 as downward, as seen in the schema. Fig. (il. To get this direction, in the 
 recumbent patient, the patient's head must be elevated, and at the same
 
 INTRODUCTION OF THE BRONCHOSCOPE. 161 
 
 time It must be closelv observed that the patient's head is neither ro- 
 tated nor bent to one side or the other. The accurate placing of the 
 head will be watched carefully by a trained assistant, but the operator 
 should also, without direct looking, be able to determine, in a general 
 way, the position of the patient's head and neck. The better the second 
 assistant and the longer he and the operator have worked together, the 
 better the work they will do and the more the operator will come, un- 
 consciously, to depend upon the assistant to keep the head in position. 
 
 Difficulties in the introduction of the bronchoscope. The foregoing 
 is a description of how to introduce the bronchoscope, and if closely 
 followed, no one after a little practice should have any difficulty in the 
 introduction in a patient fully relaxed by a general anesthetic. If any 
 serious ditliculties are met with, some of the details have been over- 
 looked, such as full extension of the head, elevation of the head, lift- 
 ing strongly with the tip only of the laryngoscope at the moment of in- 
 sertion of the bronchoscope in the glottis. ^ 
 
 The beginner will occasionallv enter the esophagus instead of en- 
 tering the trachea. This is a verv dangerous accident, in dyspneic cases, 
 not only by default in not entermg the trachea, but directly by compres- 
 sion of the trachea through the bulk of the esophagoscope in the eso- 
 phagus. Under normal conditions, if properly passed, an esophagoscope 
 docs not compress the trachea to any appreciable extent, as the author 
 has previously demonstrated by inserting, at the same time, the broncho- 
 scope in the trachea and an esophagoscope in the esophagus ; but in dysp- 
 neic cases, it takes but very little displacement of the esophagus to in- 
 crease the dyspnea to the point where respiration will be arrested. For 
 another reason it is essential to avoid putting the bronchoscope into the 
 esophagus accidentally first before introducing it into the larynx, because, 
 if properly done, the bronchoscope can be introduced through the laryn- 
 goscope without coming in contact with the secretions contaminated 
 from the mouth. The trachea is not a septic canal, while the esophagus 
 swarms with bacteria. Getting into the esophagus is simply due to the 
 neglect of some of the details just mentioned, especially insufficient glot- 
 tic exposure and defective position with failure to lift strongly with 
 the spatular tip at the moment of passing the glottis. It is not always as 
 easy as might be supposed to detect the entrance of the bronchoscope 
 into the esophagus. There is a very distinct respiratory movement to 
 the esophagus, but it is in no way equal to the ex[)iratory tracheal blast 
 and the ])ink, smooth, collapsing walls of the esophagus are in marked 
 contrast to the normal trachea in which the rings of slightly deei)er color 
 contrast with those of the almost white nuicosa covering the cartilagi- 
 nous rings. In a state of disease, lK)wever, the tracbeal nuicosa may be so
 
 162 INTRODUCTION OF THE BRONCHOSCOPE. 
 
 swollen and edematous that tlie rings are obliterated, and in children 
 there is more or less collapse of the tracheal wall during expiration, es- 
 pecially the forced expiration of cough, as illustrated in the section on 
 the normal bronchoscopic image. In the esophagus there will usually be a 
 free flow of secretion in the distal end of the tube, which obscures the 
 field : and the secretion usually flows also through the lateral opening 
 of the bronchoscope. There mav be secretions in the trachea, but it is 
 seldom the free flow that is seen in the esophagus. The main point of 
 distinction, however, is the tracheal blast, if the patient be breathing or 
 coughing. In cases of respiratory arrest, there is usually no spasm what- 
 ever, and the freely open trachea is readily recognized. In such cases, 
 however, the error of inserting the bronchoscope into the esophagus may 
 prove fatal to the patient ; not only by default in not getting prompt 
 aeration and oxygen insufflation, but also by the bulk of the bronchoscope 
 in the esophagus compressing the lumen of the trachea. In working 
 without an anesthetic, general or local, this danger is practically nil. 
 
 If the patient is profoundly anesthetized, there is no halting of the 
 rhythmic respiratory excursion, and the bronchoscope is verv readily in- 
 troduced through the glottis without the slightest resistance. If, how- 
 ever, the patient is insufficientU anesthetized, either locally or general- 
 ly, and especially if unanesthetized as in children, the glottis may re- 
 main closed for a considerable length of time. In tracheotomized cases 
 the glottis may remain closed indefinitely, and the bronchoscope should 
 be insinuated through without waiting; but in untracheotomized cases, 
 if not dyspneic, it is better to wait for the relaxation of the spasm and 
 opening of the glottis that comes with the first deep inspiration. In old- 
 er children, or in locally anesthetized adults, the command to take a deep 
 breath will usually be obeyed, especially if the necessity for deep breath- 
 ing has been repeatedly urged from the beginning. It is not advisable 
 with an incompletely anesthetized patient, especially if chloroform has 
 been used, and still more especially if both chloroform and morphine 
 have been used, to wait too long for the glottis to open, as the respira- 
 tion may cease. In these cases it is better to push the bronchoscope 
 through. In all dyspneic cases the opening of the glottis should not be 
 awaited for more than a few seconds. The bronchoscope should be 
 pushed through, not violentlv or roughly, but with the firmness and pre- 
 cision gained from the knowledge that the tube is the right size for the 
 patient, that it is properly placed, and that the patient is in the correct 
 position. 
 
 \^ery often I have found that the difticulties which beginners have 
 encountered in inserting the bronchoscope have been due to the use of a 
 gag. Very wide gagging will render the insertion of a bronchoscope, or
 
 INTROUL'CTIOX OF THlv URONCHOSCOPE. 163 
 
 even the exi)osiire of the larynx, difficult if not impossible. There is 
 no need for a gag for any other purpose than simply to prevent the pa- 
 tient biting the tube, and for this the bite block, shown in Fig. 39 is 
 ideal, because it is readily held in place at all times by the first finger 
 of tl;e second assistant, and because it does not slip, regardless of how- 
 imperfect the patient's teeth may be. 
 
 E.vploration of the trachea and bronchi. After the bronchoscopic 
 tubc-niouth has entered the trachea there will usually be encountered 
 more or less secretion, according to the nature of the case, the anesthetic 
 and drugs used. etc. This secretion must be removed at once, before any 
 deeper insertion of the bronchoscope is made in order that we have the 
 safety of sight. In foreign-body cases this is especially necessary lest 
 the intruder be pushed down. For the same reason, sponges must be in- 
 serted only just beyond the tube-mouth, which distance can be determined 
 by the sensation imparted to the finger and thumb when a properly fit- 
 ting sponge emerges from the distal tube-mouth. Having removed the 
 secretions by the author's "sponge pumping" process in the manner 
 illustrated in Fig. '2'>, and explained under "Aspirators," the broncho- 
 scope is carefully advanced. If the bronchoscope or the trachea become 
 filled with secretion coughed from the lower air passages, advance of the 
 tube must be stopped as often as necessary until the secretion is re- 
 moved, lest a foreign body be overridden or a diseased area be over- 
 looked. While it is true that the tracheo-bronchial tree is very elastic, 
 and consequently will adapt itself in a wonderful degree to the faults' 
 direction of the bronchoscope, yet it is essential, wherever possible, to 
 follow the lumen as it opens up ahead of the tube mouth. As has 
 just been said, a well-trained assistant will at the introduction of the 
 bronchoscope have the head so held that the trachea will be in line 
 ahead of the bronchoscope. In the further exploration of the tracheo- 
 bronchial tree, the second assistant should busv himself with making 
 sure that the head is so held that the lani'ux shall in the least possible 
 degree become the fulcrum upon which the bronchoscope rests. In 
 other words, when the position, into which the operator in pursuit of the 
 lumen swings the bronchoscope, causes the bronchoscoijc to bear upon 
 the larynx as a lever upon its fulcrum, the laryngeal fulcrum should 
 be eased off for two very important reasons : 
 
 1. An unyielding laryngeal fulcrum limits exploration because of its 
 distance from the upjier thoracic aperture. 
 
 2. If the larynx is not eased away when fulcral pressure comes 
 ui)on it. this pressure will cause subglottic edema. 
 
 Therefore a fundamental rule which must be rigidly observed by 
 the bronchoscopist and especially by his second assistant is: The fid-
 
 164 INTRODUCTION OF THE BRONCHOSCOPE. 
 
 ciuDi of the bronciwscopic lever is at the upper thoracic aperture; never 
 at the larynx (Schema. Fig. IS.J). 
 
 To accomplish this the head and neck must gently be made to fol- 
 low the direction of the proximal end of the bronchoscope. 
 
 The freedom of movement of head and neck, with synchronous 
 undistorted status of the thoracic cage requires the Boyce position. In 
 no other way can the same results be accomplished. The nearest ap- 
 proach to this position as to movability of the head and neck is the lateral 
 recumbent position, which is very objectionable because of the varj^ing 
 position of the thorax, the less manageable head, and the inconvenience 
 in the exploration of the uppermost lung or the alternative of turning the 
 
 Fig. 135. — Illustrating the fallacy of supposing there is a wider range of move- 
 ment possible by tracheotomic than by oral bronchoscopy. If the larynx were 
 rigidly fi.xed at L, the lateral range of movement possible would be relatively slight 
 as compared to tracheotomic bronchoscopy. But by bending the neck sharply to 
 one side we bring the larynx from H to E, permitting the use of the entire upper 
 thoracic aperture. This illustration also shows how the second assistant by easing 
 away the lar3-nx from H to E makes the upper thoracic aperture the fulcrum of 
 the bronchoscopic lever instead of the laryn.x, thus preventing undue pressure on the 
 larynx and consequent subglottic edema. 
 
 patient — a time-wasting procedure that is intolerable to anyone who has 
 experienced the comfort, satisfaction and facility of work in the Boyce 
 position of the patient maintained by an assistant who has worked a long 
 time with the operator. 
 
 To accomplish the making of the upper thoracic aperture (instead 
 of the larynx) the fulcrum of the bronchoscopic lever, the second assistant 
 must have a good general sense of direction and must have a mental pic- 
 ture of the position and direction of the long axis of the part of the 
 tube in the patient which he must gain from the uninserted portion of 
 the tube. If the tube is deeply inserted he must mentally "'line up" the 
 position of the bronchoscope in the patient from an imaginary line drawn 
 from the proximal tube-mouth to the bronchoscopist's right eye. This
 
 IXTKODL'CTION Ol" Till-: nKONCUOSCOPli. 
 
 165 
 
 line must necessarily be a prolongation of the long axis of the bron- 
 choscope. The axial line of the tube and the upper thoracic aperture 
 and their relations to each (jUkt must be constantly in the mind of the 
 second assistant. 
 
 In the descriptions before and hereafter given of various positions 
 of the head and neck it is to lie understood that these in no way inter- 
 
 FiG. 136. — Radiograph of bronchoscope in the right upper lobe bronchus of a 
 woman of 25 years. The bronchoscope was inserted through the mouth and the 
 angle is shown to be as advantageous as would be possible through a tracheotomic 
 wound. The position of the patient is easy and natural in this instance, the radio- 
 graph being made for verification of the overlay localization in a suspected case of 
 interlobar al)scess. Had demonstration been the object, the upper part of the lube 
 could easily have been l)rought to the clavicle. The lesser shadow passing down- 
 ward is from pus and shows the location of the middle and inferior lobe (stem) 
 bronchi. This radiograph also shows that the limit of lateral movement is fixed 
 by the upper thoracic aperture; not by the larynx, hence tracheotomy is of no ad- 
 vantaf^e for bronchoscopy, so far as angle is concerned. 
 
 fere with the endnscopist following lln' lumen unr the second assistant 
 following the operator. "S'et it is necessary to know, in a general wa\', 
 the jwsitions of the patient's head and neck that will be re(|uire(l prop- 
 erly to enable a correct presentation of the desired objective point. 
 
 With all the foregoing clearly in the mind of operator and assistant 
 we are readv to proceed down the trachea, determining as we go the
 
 166 INTROOrCTlON OF THE BRONCHOSCOPE. 
 
 proper direction by endoscopic watch of the wall of the trachea as it 
 opens up ahead. The endoscopist should not see either wall more than 
 the other, but with a properly directed tube should be looking directly 
 downward into the tracheal lumen. If he sees the anterior wall, which 
 is the usual fault, the patient's head must be elevated. If he sees one 
 lateral wall or the other, the patient's head must be brought to the 
 middle line. If he sees the posterior wall, which is a very rare thing, 
 indeed, with the beginner, the head may be lowered. Of course these 
 remarks should not be applied too strictly to cases in which a careful 
 inspection of the tracheal wall is desired ; but even in such cases it is far 
 better to examine the general lumen of the trachea downward before 
 making a minute inspection of the lateral wall, because it is only by keep- 
 ing the lumen straight ahead that one can determine small degrees of 
 compression or slight amounts of such diseases as perichondritis. 
 
 In passing down the trachea the following two rules must be kejJt 
 in mind : 
 
 1. Before attempting to enter either main broueJnis the earina iiutst 
 be identified. 
 
 '2. Before entering either inuin bronchus the orifices of both should 
 be identified and inspected. 
 
 These are time-saving and localizing ex])edicnts of the utmost ini- 
 ])ortance. For quick, accurate and efficient work the bronchoscopist must 
 at ail times know exactly the particular part of the tracheo-bronchial tree 
 that is being explored by the tube-mouth. With a natural faculty of 
 orientation, a practical working-knowledge of the average distances, and 
 familiarity with the endoscopic appearance of the few landmarks this is 
 easy. These things cannot be gained from a book. It is useless to 
 memorize arbitrary measured distances. The practical working-knowl- 
 edge is best obtained from a wet anatomical preparation by draining out 
 the fluid and then passing the bronchoscope, studying together the en- 
 doscopic and external anatomy of the dissected tree from which the 
 lung tissue has been remo\ed at the root of each lung. 
 
 In doing bronchoscopy on the living, after the laryngoscope is 
 removed, the bronchoscope, which was held in the right hand for in- 
 troduction, is now held between the thumb and finger of the left hand, 
 tile second and third fingers of which are hooked by their terminal 
 phalanges over the upper teeth (Fig. l.'iT ). This steadies the hand and 
 any desired depth of bronchoscopic insertion can be maintained indefinite- 
 ly with ease and accuracy by the left hand alone. This serves two very 
 im]:'ortant purposes: 1. The exact desired relation of the tube-mouth 
 to a foreign body (or tumor) can be preserved exactly for the applica- 
 tion of the forceps. 2. The right is free for the [prompt use of the for-
 
 INTRODl'CTIOX 01' TIIK liRONCIIOSCOPE. 
 
 167 
 
 ceps, as soon as the desired tubal position is established. The author 
 believes these two factors contribute largely to the success attending work 
 with distally lighted tubes. A heavy handlamp prevents this anchoring 
 of the tube in a tixed position by the fingers of the left hand on the 
 teeth. Hence, the slightest movements of the patient, e\en the respira- 
 tory movements, may disturb the relations which are relied upon to 
 
 Fir,. I,?-. — The heavy laryngoscope has 1)cen removed leaving the light broncho- 
 scope in position. The operator is inserting forceps. Note how the left hand of the 
 operator holds the tube lightly between the thumb and first two fingers of the left 
 hand, while the last two fingers are hooked over the upper teeth of the patient 
 "anchoring" the tube to prevent it moving in or out or otherwise changing the re- 
 lation of the distal tube-mouth to a foreign liody or a growth while forceps are 
 being used. Thus, also, any desired location of tlie tube can be maintained in syste- 
 matic exploration. The assistant's left hand is dropped out of the way to show the 
 operator's method. The assistant during bronchoscopy holds the bite-block like a 
 thimble on the index finger of the left hand, and the assistant should be on the 
 right side of the patient. He is here put wrongly on the left side so as not to hide 
 the instruments and the manner fif holding tlicm. 
 
 facilitate the accurate application of the forceps by sight. After an- 
 choring the bronchosco]je with the fingers of the left hand, the riglit is 
 used at the collar of the proximal end (not grasping the handle) to 
 manipulate the tube, inward, outward, downward, upward or laterally, 
 the tube being permitted to slide between the finger and thumb of the 
 left hand, if withdrawal or deeper insertion is needed. At any time it
 
 168 INTRODl^CTinx OF TltK BRONCHOSCOPE. 
 
 is instantly fixed at the desired point ; for instance wiien a momentary 
 view of a foreign body has been obtained, followed by disappearance due 
 to respiratory movement, cough, a flood of secretions. It is very im- 
 portant under such circumstances to keep the tube there until an- 
 other view is obtained. The manipulation of the tube with the right 
 hand is important. The handle of the bronchoscope is not grasped firmly 
 in the clenched hand as one would hold a revolver (A, Fig. 13S). On 
 the contrary it is held lightly, by the collar with the right thumb and 
 index finger (B, Fig. 138) the other fingers either not being used at all 
 or only to assist in rotating or balancing the instrument. The handle 
 of the bronchoscope is needed only when it is desired to rotate the bron- 
 choscope, and then it is used but slightly, being pushed around with the 
 second and third fingers of the right hand while the thumb and index 
 finger hold the collar. 
 
 A B 
 
 Fig. 138. — A, incorrect manner of holding bronchoscope. The grasp is too 
 rigid and the position of the hand is awkward. B, correct manner, the collar being 
 held lightly between the finger and tlie thumb. The thumb must not occlude the 
 proximal tube mouth. 
 
 Identification of the normal carina is easy when the orifices of both 
 main bronchi are exposed. The difficulty which beginners have is due 
 to the fact that the right bronchus is mori^hologically the continuation 
 of the trachea whereas the left is, in many cases, for endoscopic pur- 
 poses, a lateral branch. Hence, special care must be taken in searching 
 for the carina to pass down the trachea with the lip of the bronchoscope 
 toward the left (A. Fig. 139) and to make slight lateral pressure with 
 the lip of the bronchoscope on the left tracheal wall, while the head of 
 the patient is held slightly toward the right. This will result in exposing 
 the left main bronchial orifice and between it and the right is the carina, 
 which by this method should never be missed. If some detail is neg- 
 lected and the left bronchial orifice is not in evidence, it is only neces- 
 sary to withdraw the bronchoscope (not too far, lest it be brought al-
 
 INTKOnUCTlOX OF THE BRONCHOSCOPli. 
 
 169 
 
 together out of the trachea) and to start over again. Occasionally a 
 diseased condition of the carina may cause difficulty in identification, as 
 in ulceration, excessive deformity from the pressure of a mass of medias- 
 tinal lymph nodes, etc. In such cases the identification of the bronchial 
 orifices can be made by careful examination. Anomalies, such as the 
 upper lobe bronchus being given off from the trachea, might cause con- 
 fusion though in the only case of this anomaly seen by the author the 
 mistake could scarcely have been made because the orifice was found 
 only by effort. Kahler has observed diverticula of the trachea but these 
 pouches ought not to lead to error in identification of the carina. 
 
 Fig. 1.39. — Schema demonstrating the method of entering the desired bronchus 
 with the slanted end bronchoscope. Recumbent patient. A, entering the left 
 bronchus. B, the beak being reversed, the bronchoscope naturally linds its way 
 into the right bronchus. The head of the patient is to the side opposite to that 
 of the desired bronchus, and the axis of the trachea consequently is given a posi- 
 tion at a more obtuse angle to that of the desired bronchus than is shown in this 
 schema, which is intended to emphasize only the use of the slanted end. 
 
 Entering the bronclioscof'e into the right and left main bronchi. If it 
 is desired to enter the right bronchus, the patient's head is moved to the 
 left and the bronchoscope is maintained in the same position as when 
 started, namely, with the handle out horizontally to the right. If it is 
 desired to enter the left bronchus, the patient's head is moved to the 
 right and the handle of the bronchoscope is placed out horizontally to 
 the left. The purpose of turning the handle in these directions is to 
 bring the lip of the bronchoscope in proper position to facilitate the en- 
 trance of the desired bronchus, as will be understood by referring to the 
 schema, Fig. 13S).
 
 170 
 
 INTRODUCTION OF THE BRONCHOSCOPE. 
 
 Entering the bronchoscope into the middle lobe bronchus. For in- 
 troduction, the head must be high above the table in order that the 
 trachea shall be in line, as previously explained. \Mien, however, it is 
 desired to enter an anterior branching bronchus, like the middle lobe 
 bronchus, which is usually given off more or less toward the anterior 
 part of the right stem bronchus, below the giving off of the upper lobe 
 bronchus, it is necessarv to lower the head and to some extent the shoul- 
 ders of the patient, as seen in the schema. Fig. 140. To accomplish this 
 lowering, it is necessary to have the shoulders of the patient well out in- 
 
 TT 
 
 Fic;. 140. — Schema illustrating' tlie entering of tlie antc-rinrly lirancliing middle 
 lobe bronchus. T, trachea. B, orifice of left main bronchus at bifurcation of 
 trachea. The bronchoscope, S, is in the right main bronchus, pointing in the di- 
 rection of the right inferior lobe bronchus, I. In order to cause the lip to enter the 
 middle lolie bronchus, M, it is necessary to drop the head so that the bronchoscope 
 in the trachea T T, will point properly to enable the lip of the tube mouth to enter 
 the middle lobe bronchus, as it is seen to have done at ML. 
 
 to the air toward the operator. The ridge of the patient's scapulae should 
 be at the edge of the table. This will give the widest range of move- 
 ment. In entering the middle lobe bronchus the slanted-end broncho- 
 scope is much superior to any other shape as will be understood by look- 
 ing at the schema, Fig. 141. 
 
 The method of entering the bronchoscope into the I'urioiis branch 
 bronchi is the same in [jrinciple as the entering of the middle lobe bron- 
 chus. That is, the lip of the slanted-end bronchoscope is brought to the 
 mouth of the branch bronchus by rotation of the bronchoscope until the
 
 IXTRODIXTION OF TIIK BRONCHOSCOPE. I'i'l 
 
 handle corresponds to the general direction of the branch bronchus. Then 
 the head and neck of the patient are swung to the opposite direction more 
 or less strongly as needed. The bronchoscope, which has been kept a 
 little above the orifice of the branch bronchus, is now pushed downward, 
 the lip making slight pressure on the wall as it goes, so that when the 
 mouth of the branch bronchus is reached, the lip will slip in. If tlie 
 orifice cannot be thus found, the reverse method may be used. That is 
 the bronchoscope is inserted down the stem bronchus past where the 
 orifice must be. ( )n withdrawal the lip of the bronchoscope is pressed 
 firmly against the lateral wall so that when the orifice is reached the lip 
 will spring into the orifice, or, rather, the ridge corresponding to a 
 carina will suddenly appear in the endoscopic image. This reverse method 
 is especial!)- undesirable in foreign-body cases because the foreign body 
 may be pushed farther into the branch bronchus. 
 
 Biitcring the bronchoscope into the upper lobe bronchus is done by 
 the method just described, the maneu\er being facilitated by moving the 
 tube to the corner of the mouth opposite to the side of the desired bron- 
 chus, and by displacing the head an<l neck far down to this opposite side, 
 also Ix'ing careful to have the li[) of the brunchoscope in the proper 
 direction (Fig. HI). If it is remembered that the fulcrum of the 
 bronchoscopic lever is, or should be, the upper thoracic aperture ( Fij?- 
 135) there need be no difficulty in entering the stem of the upper lol)e 
 bronchus of either side (Fig. 111). A greater depth is explorable on 
 the right than on the left side. It is not possible to get a lumen image, 
 but the short stem can be entered as far as the giving ofif of the first 
 branches, and this is the part in which foreign bodies are most likely 
 to lodge. Even in this location they are exceedingly rare. There is 
 no need of tracheotomy for exploration of the up])er lobe bronchus 
 because no more of it can be explored by thai route nor is it more easily 
 thus entered, as exi)laine(l on a future page in discussing the relative 
 merits of oral and tracheotomic bronchosco])y. The limitations are fixed, 
 not by the larynx, but by the upper thoracic aperture. The orilice of the 
 up])er lobe bronchus on the left side may be looked for at about 4 cm. 
 after passing the bifurcation. ( )n the right side it may be 1 cm. or "^ cm. 
 from the Ijifurcaticn, but it should be looked for at once after entering 
 the right main bronchus. In estimating desired depths of insertion, the 
 quickest method is to move the finger and thumb of the left hand up on 
 the tube the required distance from the teeth. Then the tube is in- 
 serted until the tlnmib and finger are felt to reach the teeth. This seems 
 simple, easy and (|uickly done as compared to reading numbers in a 
 darkened room ; but many operators prefer to read off the graduation 
 marks on the outside of the tube and the endoscopist may choose for
 
 1T3 INTRODUCTION OF Tllli BRONCHOSCOPE. 
 
 himself. The author never uses either method, preferring to gauge the 
 depth by the endoscopic image as the tube is advanced or withdrawn. 
 
 Bronchoscopy in children. The technic of bronchoscopy in children 
 is precisely the same as just described for the recumbent position in 
 adults. The author of late years has not used any anesthetic, general 
 or local, for children under six years of age. This increases the diffi- 
 culties somewhat, yet it brings the risk of bronchoscopy down to noth- 
 ing, eliminates complications, and it has the advantage of rapidly get- 
 ting rid of secretions. The recumbent position is best, in the author's 
 opinion, for reasons already herein given. One precaution necessary in 
 children is to see that they do not arch up the chest. If they do, the 
 nurse who holds the two hands, uses her right hand to press the chest 
 
 Fig. 141.— Schema illustrating the advantage of the slanted-end bronchoscope 
 for entering branch bronchi, especially the upper lobe bronchus. When the squarely 
 cut off bronchoscope (e) is lowered to the most advantageous angle possible, as 
 shown by the dotted lines, the mechanical difficulty is still great as compared to 
 the slanted-end bronchoscope as shown by the dotted lines (/). 
 
 gently down on the table, without letting go tlie left arm of the child, 
 carrying the child's arm witli her hand. Children are particularly sub- 
 ject to subglottic edema, especially if too large a tube be used, or the be- 
 fore-mentioned precautions to avoid the fulcral pressure on the larynx 
 are neglected. In addition, of course, all of the niceties of bronchoscopy 
 must be practiced in the bronchoscopy of children, because of the delicacy 
 of the tissues. The 4 mm. tube should be used as a rule for infants un- 
 der about ten months. The author uses it for one year and under. The 
 author has special forceps for the i mm. tube. These forceps can be 
 seen to close; and all of the manipulations in foreign-body extraction 
 can, and should be, done under the guidance of the eye. Brimings' state-
 
 INTKOUUCTION 01- THE ISROXCIIOSCOPE. 
 
 173 
 
 Fic. 1-1-'. — bronchoscopy by BriiniiiKS nicthoil. The laryiiKoscopic tube is intro- 
 duced through tlie glottis with the riglit Iiand. Then the inner tu1)C is inserted with 
 the left hand, as shown in the upjier illustration. When forceps or other instru- 
 ments are to be used the laryngo-bronchoscope is transferred to the left hand as 
 shown in the lower illustration.
 
 174 INTRODUCTION OF THK BRONCHOSCOPE. 
 
 ment that ocular guidance "'is largely an illusion" can refer only to 
 proximally lighted tubes. 
 
 Introduction of the Bri'tnings bronchoscope. The introduction of the 
 Briinings bronchoscope is, in principle, precisely the same as just de- 
 scribed up to the exposure of the glottis. At this point, the distal end of 
 the Bri.inings laryngoscope, which is intentionally small for this very pur- 
 pose, is itself pushed through the glottis into the trachea, then the bron- 
 choscopic extension inner tube is inserted and pushed down the required 
 distance and locked with the ratchet, shown in Fig. 4. In order to pre- 
 vent loss of time in cleaning the mirror, Briinings advises that every 
 time the patient is about to cough, the mirror carrier should, if possible, 
 be swung to the operator's left side. The Briinings method differs from 
 that of the author in the uses of the operator's hands as shown in Fig. 
 143. The operator protects the lips with the left hand, while introducing 
 the laryngoscope grasped with the right hand. The epiglottis is identi- 
 fied, the tip of the laryngoscope is inserted beyond it, but not too far, 
 as previously described. Then the epiglottis is lifted, ( recumbent pa- 
 tient) and the glottis is exposed. As before explained, under no cir- 
 cumstances should any attempt be made to expose the glottis until the 
 epiglottis has been identified, nor should any attempt be made to insert 
 the instrument through the glottis until the cords are seen and identi- 
 fied with certainty, in at least their posterior third. Briinings con- 
 siders it not absolutely necessary to wait for the complete abduction of 
 the cords, as the beak of the instrument can be pushed through, if the 
 instrument is exactly in the middle line. In difficult cases digital coun- 
 terpressure externally on the larynx may be used to assist in exposing 
 the cords ; and in cases of incomplete anesthesia the instrument may be 
 rotated so as to insert the wedge-shaped beak of the laryngoscope in the 
 long axis of the glottis. Having inserted the laryngoscopic tube into the 
 trachea with the right hand, the inner sliding tube is inserted with the 
 left hand (Fig. 143). The laryngoscope is not removed as the bron- 
 choscopic tube slides in at a close fit and becomes, when locked with 
 the ratchet shown in Fig. 4, a rigid part of the laryngoscope itself. When 
 it is desired to use forceps, swabs, aspirator or other instrument, vhe 
 laryngo-bronchoscope, which up until this stage has been held in the 
 right hand, is now transferred to the left hand so that the right is free 
 for the use of forceps as shown in Fig. 142. Briinings states that when 
 insurmountable obstacles to the passage of the instrument are encoun 
 tered, it is usually possible to succeed by putting the patient on his left 
 side, with the head supported. Then the instrument is passed as in the 
 sitting position. He states that he occasionally also uses the ventral 
 recumbent position which he finds particularly easy. The illustrations,
 
 INTKODVCTION OF THK DRONCHOSCOPE. I'J'S 
 
 Fig. 142, are reproduced, \>y iicnnission, from Bninings'excellent treatise. 
 '•Die direckte Laryngoskopie, Bronchoskopie und Esophagoskopie," of 
 which an excellent English translation, by ^Ir. Walter G. Howarlh, is 
 published by Messrs. Bailliere, Tindall and Cox. 
 
 The introduction of the Kahlcr bronchoscope is precisely the same 
 as just described for the P>runings instrument. 
 
 THK NOKM.VL BRONCHOSCOPIC IM.\GE. 
 
 In the author's earlier ])ulilication (Bib. 209) were shown a number 
 or normal and pathologic endosco])ic illustrations which show in such a 
 satisfactory way the living appearances that no new colored illustrations 
 are here added. 
 
 The color of the mucosa as seen endoscopically varies with the degree 
 of illumination. With a dull glowing filament the normal mucosa may 
 seem dark red; with the bright, white light of a fully illuminated tung- 
 sten filament the same mucosa will seem pinkish white ; while, with an 
 over-illuminated filament, the mucosa may seem grayish white. The 
 color of the normal mucosa also varies with the anesthetic. With chlor- 
 oform the mucosa is paler than with ether, the difference being due 
 not to local irritation, but to the engorgement of the vessels from the 
 general stimulant effect of ether. Cocaine, by the ischemia it causes, 
 if applied before the bronchoscope is deeply introduced causes the color 
 of the mucosa to appear a paler pink, .\drenalin has an even more 
 marked effect in whitening the endoscopic image. Neither of these act 
 to the same extent if applied after the bronchoscopic examination has 
 coiuinued for some time in the examined locality. The ridges between 
 the orifices of branching bronchi are. under all ordinary conditions, nor 
 mally of a glistening whitish color with only occasionally a slight tinge 
 of pink. Their color often leads them to be mistaken by the beginner 
 for a thread of mucus or a foreign body, such as a bright pin. 
 
 It may be said, then, that the color of the mucosa as seen endoscop- 
 ically, may, in health, vary from almost white, through yellowish pink, 
 bluish ])ink, pale red to dark red. depending upon illumination and vas- 
 cularity. 
 
 The form of the endoscopic picture depends upon the angle at which 
 the lumen is i)resented, this being in turn dependent upon, ( 1 ) the ])osi- 
 tion of the tube, and, ( 2 ) the position of the parts examined. .\s both 
 are constantly changing, the variety of forms in the eiuloscoiiic picture 
 is almost cntUess. The respiratory, bechic, pulsatory, reflex and trans- 
 mitted muscular movements and compressions so modify the normal 
 image that nothing but study of the image, as seen in the living, will
 
 176 INTRODUCTION OF THE BRONCHOSCOPE. 
 
 educate the eye, as elsewhere meiilioned. When the axes of the bronchial 
 and the bronchoscopic lumhia exactly correspond, the lumen of the 
 bronchus seems to diminish more or less concentrically owing to per- 
 spective, and the orifices of the branch bronchi with the white shining 
 ridge between are seen beyond (Fig. 143). These views represent com- 
 plete images which are momentarily obtained. Movements of the vari- 
 ous kinds mentioned are constantly hiding the orifices and ridges that 
 are a centimeter or more beyond the tube-mouth. These are accurately 
 presented images. When the axis of the bronchoscope deviates from 
 coincidence with the luminal axis, more or less of the wall toward which 
 
 Fig. 143. — Normal endoscopic images. Semiscliematic. i. Left main bronchus. 
 S, left upper lobe bronchus. I, left inferior lobe bronchus (or "stem" bronchus), 
 showing dorsal and ventral branches. 2. Right main bronchus. SL, superior lobe 
 bronchus. M, middle lobe. I, lower lobe bronchus showing orifices of dorsal and 
 ventral branches. The main bronchus (right or left) below the upper lobe 
 bronchus is usually referred to as "stem" bronchus because there is no true bifurca- 
 tion, only a giving off of lesser branches from the stem. 
 
 the tube-mouth de\iates, is seen. I'.y the form and position of the rings 
 seen in perspective in the bronchial wall it is possible to estimate how 
 far the luminal axis deviates from the bronchoscopic axis, and thus the 
 direction of the particular branch bronchus may be estimated. By the 
 same means the proper direction in which to move the tube to obtain a 
 view directl)- into the long axis of the lumen is known. C)n the posterior 
 tracheal wall, the "party wall.'' the signs of rings are absent. Else- 
 where in the normal trachea the ring-like appearance is more or less 
 marked by differences in color. The membranous inter-spaces are usual- 
 ly of deeper color than the prominences corresponding to the cartilage.
 
 INTRODUCTION OF THE BRONCHOSCOPE. 177 
 
 If tlie tracheal mucosa is edematous, iuliltrated, or very much engorged, 
 the rings may nut be visible. The ringed appearance of the wall dimin- 
 ishes as we go downward untii it is not noticeable in the smallest bronchi, 
 though it is not missed because the orifices make more or less of a ringed 
 appearance in the endoscopic image. 
 
 The posterior tracheal wall is ordinarily somewhat flattened and may 
 even assume a convex form as it bulges forward into the trachea during 
 cough, especially in children examined without, or with only slight, anes- 
 thesia (Fig. 144). In addition to the posterior wall, there is a flattening 
 often visible at the aortic crossing and also at the bifurcation, these being 
 in some instances continuous with each other. A slight flattening in the 
 
 /^N 
 
 Fic. 144. — Endoscopic view showing forward bulging of the posterior mem- 
 branous tracheo-esophageal wall during cough. Patient dorsally recumbent. Not 
 patliological. Seen mostly in children, and accentuated w-hen the bronchoscopic tube 
 mouth bears too much on the posterior tracheal wall. 
 
 neck at the level of the thyroid gland cannot be called pathological. All 
 of these flattenings are usually from before backward, though the longest 
 diameter of the tracheal cross-section is seldom exactly in the lateral 
 plane. 
 
 The orifices of the dorsal and ventral branch bronchi are not opposite 
 each other in the stem bronchus. The inferior lobe bronchi in some cases 
 end in a sort of axis, where two or more branches are given off at nearly 
 the same level, which is in contrast to the nionopodic branching higher up.
 
 CHAPTER X. 
 
 t 
 
 Introduction of the Esophagoscope. 
 
 Indicailons and contraindicatiuns for esophagoscopy will be consid- 
 ered under "Foreign Bodies" and under "Diseases." The remarks there 
 made on contraindications, especially, should be read before attempt- 
 ing the introduction of the esophagoscope. 
 
 Anesthesia and position of the patient for esophagoscopy have al- 
 ready been considered in a separate chapter. 
 
 NORMAL NARROWINGS OF THE ESOPHAGUS. 
 
 He who contemplates attempting esophagoscopy for the first time 
 should fix in his mind certain general principles, anatomical and mechan- 
 ical, that are known to experienced esophagoscopists, but which have 
 never before been put in concrete form for the preliminary study of 
 the beginner. These may be classed under two heads: 1. The normal 
 narrowings of the esophageal lumen as seen endoscopically. 2. The nor- 
 mal direction of the esophageal lumen, esophagoscopically considered. 
 
 The esophagus is not a flaccid tube through which an endoscopic tube 
 can be rudely pushed. Nor is it a straight tube. It deviates and has cer- 
 tain narrowings, some of which are constant anatomic decreases of lumen. 
 Others are due to pressure of surrounding structures that, viewed endo- 
 scopically, give one the idea that the esophagus was put through first, 
 and then all of the surrounding structures were tamped in around it like 
 the stones and earth around a post in a post-hole. Other narrowings, 
 and these are the most troublesome, are the spasmodic ones, due to the 
 contraction of periesophageal musculatures. There are, also, spasmodic 
 contractions, less powerful, of the circular muscular fibers of the esoph- 
 ageal wall itself. Mehnert (Bib. 404), in a very elaborate paper on the 
 anatomy of the esophagus, describes thirteen physiological constrictions 
 in the esophagus. The esophagoscopist, however, will usually be able
 
 INTRODITTIOX Ol" TlIK KSOl'lI AGOSCOPE. JTO 
 
 to demonstrate but five. 1. The cricophaiyngeal fold. 'L The crossing of 
 the aorta. 3. The crossing of the left bronchus, i. The hiatus esophageus. 
 r>. The upper thoracic aperture. Some esophagoscopists beHeve in a con- 
 striction at the cardia itself. In the author's opinion there is certainly no 
 spliincter at the cardia and he cannot but think that the constriction noted 
 by some observers is due, in some instances, to the intra-abdonilnal pres- 
 sure ; in others to mistaking for the cardia the compression produced by 
 the narrowing of the hiatus esophageus through the action of the diaphrag- 
 matic musculature. 
 
 These narrownigs are largely due to static or contractive pressure of 
 surrounding structures. The esophagus itself is so thin-walled a struc- 
 ture that its narrowings, even under spasmodic contraction of its own 
 musculature, are of less endoscopic importance than the peri-esophageal 
 musculature, are of less endoscopic importance than the periesophageal 
 structure. It is elsewhere stated that it is necessary to relax the eso- 
 phageal musculature in order that trauma be not done during the extrac- 
 tion of a very large and sharp foreign body. It is true that the con- 
 tractions of the esophageal musculature are sufficient to permit of its 
 laceration b\- the withdrawal of a foreign body when the musculature 
 is spasmodically contracted, yet it is the surrounding musculature acting 
 upon the surrounding hard and soft parts adjacent to the esoi)hagus that 
 is in large part res])onsiblc for trauma in the willulrawal ul foreign 
 bodies as well as fur the iliflicullies in the introduction of ihe esoph- 
 agoscope. 
 
 The cricopliaryih/cal cuiislriclio)!. In a previous chapter it was stated 
 that a knowledge of endoscopic anatomy cannot be learned from books ; 
 and to a certain extent it cannot be learned from the cadaver. No- 
 where is this better exeni[)lilied tiian in the study of tile cricopharyn- 
 geal constriction of the espohagus. In the cadaver this constriction is 
 widely open ; and prior to the days of cso])hagoscopy it was supjiosed 
 to be open in life. This has been called tiie "mouth'" of the esophagus: 
 but, as by the ''mouth" of the esophagus esophagoscopists do not refer 
 to the crescentic crevice. (Tig 1, I'late III) visible by direct or indirect 
 laryngoscopy back of the arytenoid eminence and aryepiglottic folds, 
 where these meet the postero-lateral pharyngeal wall, much confusion 
 might result and the author ])roposes the term "cricopharyngeal con- 
 striction." This crevice is the entrance to the hypopharynx which ends 
 below (in the unanesthetized living subject) in a physiological narrow- 
 ing, which, in life, looks as tliough it were being drawn togctiicr inter- 
 mittently by a purse-string outsi<le the esoiihageal wall. This narrow- 
 ing, in the adult, is about two centimeters in extent and is noticeable Imtli 
 on introduction and withdrawal of the esophagoscope. As this con-
 
 180 INTRODUCTION OF THE ESOPHAGOSCOPE. 
 
 striction is more or less circular, though muscularly incomplete anterior- 
 ly, it might be called a sphincter; but this is objectionable because some 
 esophagoscopists believed in a sphincter at the cardia and spoke of "up- 
 per and lower sphincter." As the author has demonstrated, the lower 
 constriction is at the hiatal level — not at the cardia. Therefore, the 
 author suggests as a more accurate, and hence better, nomenclature "crico- 
 pharyngeal constriction" and "hiatal constriction." If deemed justi- 
 fiable, a "cardial constriction"' may be added. Hut true sphincter there 
 is none, in the esophagus. 
 
 The lower circular bundle of fibers of the inferior constrictor is very 
 powerful, much more so than the orbicular fibers of the esophagus into 
 which they merge. (See illustration in chapter on "DiverticuKuii of 
 the Esophagus.") The median raphe, which receives the insertion of 
 the oblique fibers above, is wanting below, and the contraction of these 
 circular fibers causes the greatest diiiiculty in the way of introduction 
 of the esophagoscope, and it is the one thing above all others in which 
 continual practice is necessary in order to acquire skill and confidence. 
 The cricopharyngeal constriction and the fact that it is caused by the 
 inferior constrictor were recognized by Mikulicz ; but it remained for 
 Killian to demonstrate that only the circular fibers were concerned, and 
 he also demonstrated the fact that there is a weakly supported point 
 between the fundiform and circular fibers, at which weak point the 
 esophageal wall is herniated to fomi the pulsion diverticula of Zenker, 
 as illustrated in the Section on Esophageal Diverticulum. The author 
 has noted in two instances of esophagoscopic perforation that inex- 
 perienced operators had pushed the esophagoscope through the wall at 
 this same weak point. The author wishes especially to emphasize the 
 vital importance of these two observations. (1) // the esopha^/oscope is 
 allozved to follozv its natural route and is forcibly pushed downward it 
 will certainly perforate this z^rak point, into zvhich it naturally is guided 
 by the surroundiny tissues. {2) This tendency is to be combated, in the 
 recumbent position, by forcing the tube mouth anteriorly (and slightly 
 medianwards) zcith the left hand, as soon as tin- bottom of the pyrifomi 
 sinus is readied, as hereinafter described. The constriction at the mouth 
 of the esophagus is to a great extent relaxed under profound general 
 anesthesia ; but local anesthesia has only a slight relaxing effect upon it. 
 What little relaxation there is, is due to the slight lessening of reflex ex- 
 citability. No endoscopist expects to use a general anesthetic in any 
 but exceptional cases ; and children should not have either a local or 
 a general anesthesia because of the peculiarly grave risks they intro- 
 duce into esophageal cases. Therefore, it is very desirable that the be-
 
 INTKnillTTlON III" Tin-; KSOPII AGOSCOPE. -181 
 
 ginner in esophagoscopy should tirsl devote especial preliminary study 
 to the upper end of the esophagus. 
 
 The best method of studying this region, in health or disease, is with 
 the esophageal speculum (Fig. -^1 ) used gently. It requires considerable 
 force to pull the cricoid forward. Killian, who tried it on a tracheotom- 
 ized patient b}- means of a hook passed through the tracheal wound and 
 up into the cricoid ring, described the resistance as '"enormous." The 
 h_\l)oiihar\-nx was watched in the laryngeal mirror and could be inspected 
 but the mouth of the esophagus could not be made to gape. The use of 
 the esophageal speculum (Fig. 21 ) on the living subject and on the cada- 
 ver will, by contrast, demonstrate that the larynx is supported in position 
 by a powerful tonic mustular activity in life. As shown by Killian, this 
 muscular tonicity is only relaxed by central impulses such as in degluti- 
 tion, emesis and singing. The hypopharynx can be studied by von 
 Eicken's method of hypopharyngoscopy. The larynx is cocainized and a 
 stiff steel rod bent to the "laryngeal curve" of indirect instruments and 
 having a rounded probe poirit, is inserted into the larynx and used to 
 pull the whole larynx forward, while the hypopharynx is watched in the 
 laryngeal mirror. This in favorable cases will expose the hypopharynx 
 down to the level of the middle of the cricoid cartilage. This cartilage 
 usually shows whitish under the mucosa. 
 
 'J'lic apcrtura! iiarrozciiui (if the t'sol^liuyiis requires experience to 
 demonstrate esophagosco])icall.\', but is amply demonstrated by the lodg- 
 ment of foreign bodies. ( See Chapter X\TI1. 1 
 
 Tlic aortic nairowing of the esophagus. In the living, the mouth of 
 the eso])hagus will seem the narrowest part of the esophagus as seen 
 endoscopically ; but in the cadaver the aortic constriction may be the 
 narrowest point in the esophagus. The level of this aortic constriction 
 is determined by making slight pressure with the tube-mouth against 
 the left anterior wall of the esophagus when the actively pulsating aorta 
 will be readily palpated with the tube. Otherwise the aortic narrowing 
 nia\- not be noticed at all in the author's "high-low" method of esoph- 
 agoscopv. Faulty positions, by compelling faulty tubal direction, may 
 bring the aorta into conspicuous, even obstructive prominence. Thi.s 
 is esiiccialh' true of a Iciw ln'ail at ibe start, as in the Rose position 
 As explained later, the head should not be dropped until the tube-mouth 
 is beyond this point. The normal aortic pulsation usually is so great that 
 the beginner is apt to think it juithologic. The displacement of the 
 esoi)hageal wall by the aorta is beautifully shown in the bismuth radio- 
 graphs re])roduced in the Section on .Sj^asmodic Stenosis. The aortic 
 constriction is about '-'•') cm. from the upi)cr incisor teeth in the adnlt.
 
 182 INTRODUCTION OF THE ESOPHAGOSCOPE. 
 
 The approximate distance in children is given in the author's esophagos- 
 copic chart, Figs. 14") and 140. 
 
 The bronchial narrowing of the esophagus is due to the backward 
 displacement caused by the left bronchus which crosses anterior to the 
 esophagus at about 27 cm. from the upper teeth, in the adult. The ridge 
 obsen'able esophagoscopically, Fig. (S, Plate III, is quite prominent in 
 some patients, esjjecially those with dilatations from stenoses lower down. 
 If the tube-mouth is made to bear hrnilv on the anterior wall on the way 
 down, the ledge corresponding to the bronchial crossing can be made to 
 come out very prominently. 
 
 The hiatal narrox^-ing is both anatomic and spasmodic. The eso- 
 phagus is narrowed markedly as compared with the suprajacent eso- 
 phagus : and the peculiar arrangement of the tendinous and muscular 
 structure of the diaphragm acts on this hiatal opening in a way to con- 
 strict it most powerfully. Besides this there is a local musculature demon- 
 strated by Liebault ( Ijib. 33!) ) that also contributes to spasmodic closure. 
 The level of the hiatus in the adult is about 'M\ cm. from the upper in- 
 cisors in the extended position of the head. The approximate distance 
 in children at various ages is given in the author's esophagoscopic chart 
 Figs. 140 and 14(i. 
 
 The cardia will be considered under the head of spasmodic stenoses. 
 
 The approximate distances of the esophageal narrov\'ings from the 
 upper teeth as given in the chart ( Fig. 14-") ) are necessarily subject to in- 
 dividual variation, a variation witli different body-lengths in children of 
 the same age, a variation with posture, coughing, breathing, retching, 
 swallowing, etc. Moreover, the aorta and the left bronchus are rounded 
 and do not cross at a right angle to the esophageal axis. For all of these 
 reasons absolute accuracy is impossible. Therefore, the measurements 
 were made to read in even centimeters. Xotwithstanding all of these 
 variations the distances given will Ijc found verv useful, practically, and 
 much more accurate for the li\ing than cadaveric tables. The chart is 
 arranged as the operator will encounter the narrowings on the way down, 
 with the patient in the recumbent position. The measurements were tak- 
 en with the head extended 
 
 The direction of the esophagus is very important to the endoscopist 
 for on a thorough knowledge of this depends the easy and safe intro- 
 duction of the esophagoscope. The esophagus enters the chest in a di- 
 rection decidedly backward as well as downward as shown in the schema 
 (Fig. 04) of the direction of the trachea, which is nearly parallel, the 
 esophagus lying behind the trachea. This backward direction of the 
 esophag^is is maintained as though the esophagus were trying to get 
 behind the aorta, heart and left bronchus. Below the left bronchus the
 
 INTRODUCTION OF THE ESOPHAGOSCOPE. 
 
 183 
 
 ly 
 
 3^5 
 
 6yrs 
 
 Oyrs 
 
 I4yrs. 
 
 GHEATCR curvature: 
 
 LEFT BRONCHUS M N 
 
 CRICOPHARYINSEUS 
 
 ESOPHAGOSCOPIC 
 
 AND 
 
 GASTROSCOPIC 
 CHART 
 
 ■ ' ■ ■ ■ ^— "^ —• 
 
 Fig. 145. — The autlior s esopnagoscopic chart ol approximate distances of the 
 csophaReal narrowinss from the upper incisors prepared by the author from meas- 
 urements in tlie liviui;. Arranged for convenient reference during esophago^copy in 
 tin- dorsally recumbent patient.
 
 184 
 
 INTRODUCTION OF THR ESOPHAGOSCOPE. 
 
 ES0PHAG05C0PIC 
 
 AND 
 
 GA5TR05C0PIC 
 CHART 
 
 CRICOPHARVINGEUS 
 
 AORTA 
 
 LErT BRONCHUS 
 
 HIATUS 
 
 GREATER curvature: 
 
 ADULTS I4yr>, lOyrs. 6yrs. 3yrs. lyr. BIRTH 
 
 Fig. 146. — The author's esophagoscopic chart arranged for convenient refer- 
 ence in the sitting or laterally recumbent patient.
 
 INTRODUCTION OK THE ESOPII AGOSCOPE. 185 
 
 esophagus turns forward, which thrcction it maintains until it passes 
 through the liiatus antl reaches the stomach. In ackhtion to the antero- 
 posterior curvature of the esophagus just descrihed, there is a lateral 
 deviation to the left in the thorax, which partly accounts for the esoph- 
 agus passing back of the left bronchus. The other part is accounted 
 for b\- the fact that the trachea deviates slightly toward the right in ap- 
 proaching the bifurcation as though to get its a.xis more nearly in line 
 with the right bronchus. The slight deviation of the esophagus to the 
 left in the middle half of its thoracic portion is of less importance, endos- 
 copicallv. than the very marked deviation of the lower esophagus to the 
 left before and after passing through the hiatus. In considering the an- 
 teroposterior and lateral deviations the endoscopist must fix in his mind 
 that the esophagus enters the chest in a backward and downward direc- 
 tion (anatomically) until below the level of the left bronchus, then it 
 curves markedly forward and to the left. Mikulicz thought it necessary 
 to put an angle of loO degrees in his esophagoscope to get forward 
 through the hiatus. But with the patient in the ])Osition developed for 
 the author by Dr. John W. Boyce, the patient's anatomy is so easily 
 controlled that the straight and rigid esophagoscope can be inserted 
 through the hiatus with the greatest ease, by careful attention to the de- 
 tails hereinafter given of the author's "high-low" method of esoph- 
 agoscopy. 
 
 Specular csophagoscopy. As a rule, before introducing the esoph- 
 agoscope for any purpose, the hypopharynx and cricopharyngeal con- 
 striction should be inspected carefully with the speculum, Fig. 21. If this 
 be not at hand, a fairly good inspection can be made with the laryngeal 
 speculum. This is necessary for growths high up and for traumatism 
 due to foreign bodies or to attempts at removal ; or the foreign body it- 
 self may he located in this upper region. If so. it may be overridden by 
 the esophagoscope, and it would be, in any event, much more easily re- 
 moved through the esophageal speculum. Another very important point, 
 especially in children, is that a retropharyngeal abscess may have bur- 
 rowed down on the posterior wall until it has produced serious difficulty 
 in swallowing ; and such a condition might easily be overlooked with the 
 esoi)hagoscope, though plainly visible with the esophageal s])eculum, or 
 with the direct laryngoscope. Of course dyspnea is much more apt to 
 be a symptom, Init the author has seen one case which was totally free 
 from dyspnea, the child being brought for dysphagia. 
 
 Technic of s(<ccular csophagoscopy. The use of the esophageal spec- 
 ulum (Fig. 21 ) is precisely the same as direct laryngoscopy by the 
 method described for the author's laryngoscope, in both the sitting and 
 recumbent positions. The recumbent position is preferable for reasons
 
 186 INTRODUCTION OF THE ESOPH AGOSCOPE. 
 
 previously given, and for foreign-body work is, in most instances, much 
 more certain of successful extraction of the intruder. Secretions are 
 less troublesome to the operator and, by not overflowing into the larynx, 
 to the patient. Children are more easily controlled, no anesthesia being 
 used, as elsewhere explained. Having exposed the larynx as shown in 
 Fig. 1, Plate III, by the method shown in Figs. 78 and 92 (according to 
 whether the patient is in the sitting or the recumbent posture) the spat- 
 ular tip of the esophageal speculum is inserted into the right pyriform 
 sinus (left in the sitting patient). From now on downward the spec- 
 ulum is gently insinuated as a tube, the very powerful anterior dis- 
 placement necessary for direct laryngoscopy and for other methods of 
 exposing this region is not necessary with the author's speculum because 
 the sloping end of the speculum rides forward readily with a slight an- 
 terior pull, and exposes the cricopharyngeal constriction. This is 
 readily identified with the speculum by the anteriorly convex, crescent- 
 shaped fold that e.xtends forward from the posterior hypopharj-ngeal 
 wall at the level of the lower third of the cricoid cartilage (Fig. 3, Plate 
 III ). The forward projection of this fold hides the esophageal lumen be- 
 low and it forms a chute which throws forward a bougie, esophagoscope 
 or other instrument causing the instrument to override and pass the 
 foreign body just below the lip. Strong anterior traction on the larynx 
 docs not open the lumen any wider because the i)osterior hypopharyngeal 
 wall, with the cricopharyngeal folds, follows the cricoid forward, the 
 esophagus remaining closed. In Fig. 10, Plate III, is shown the manner of 
 drawing back this posterior fold with the alligator forceps, exposing a 
 coin wedged in the esophagus below the fold. The speculum is long 
 enough to be pushed on downward flattening the fold and exposing in the 
 open trough of the speculum the posterior esophageal wall below the fold 
 for examination or operation. A careful study of this fold and its chute- 
 like action must be made with the speculum to be understood, because the 
 fold, as such, is not so noticeable in the introduction of the esophago- 
 scope. though the obstruction is felt very markedly. The weak point in the 
 esophageal wall between the horizontal and oblique fibers of the inferior 
 constrictor is just at the proximal base of this fold, and if the angle of 
 introduction is bad or the force too great an esophagoscope will not be 
 chuted forward, but will perforate and the beginner, strange as it may 
 seem, does not discover his error. He passes his esophagoscope on down- 
 ward with little resistance between the layers of tissue into the medias- 
 tinum not realizing the difference between the walls of the false passage 
 and the esophageal wall. In one such case the author was asked to look 
 through the esophagoscope to identify a shining gray membrane that was 
 puzzling the surgeon by obstructing the way. The author could not iden-
 
 INTRODUCTION 01" TIIIC ESOPH AC.OSCOPK, 187 
 
 tify the membrane, but on withdrawing the esophagoscope the layers o£ 
 connective tissue revealed a false passage. From the depth of insertion 
 it was probable that the membrane w'as the pleura though no post mortem 
 could be obtained. There was extensive emphysema. Death apparently 
 was due to vagitis and mediastinal emphysema. The false passage began 
 (B. Fig. 15;3) just above the cricopharyngeal fold. 
 
 An excellent view of disease of the posterior wall as seen through 
 the esophageal speculum is shown in Fig. 9, Plate 111. 
 
 Technic of the introduction of the esophagoscope, patient recumbent. 
 In his early w-ork the author used a mandrin but he soon found that 
 both foreign bodies and disease might be overridden ; therefore, he de- 
 veloped the technic of passing by sight and now fmds it so much easier 
 in all cases, as well as so much safer in disease high up, and so invariably 
 contributes to successful foreign-body removal, that he would not con- 
 sent to the use of a mandrin under any circumstances. In his earlier 
 work, it was customary with the author to apply sterile vaseline to the 
 esophagoscope before passing. Later experience has proven this to be 
 unnecessary, because the secretions sufficiently lubricate the instrument, 
 and it is f|uitc a relief not to have any greasy substance about the in- 
 strument table, or on the instruments introduced. 
 
 As in bronchoscopy (Fig. 187) the esophagoscope can be "anchored" 
 at any desired depth by hooking the phalanges of the left fourth and 
 fifth fingers over the jjatient's upper alveolus. In the author's method 
 of passing the esophagoscope by sight fi\e things are essential: 
 
 1. The correct "high-low" position-sequence of the patient. 
 
 'i. A knowledge of the endoscopic anatomy in the living as de- 
 scribed in this chapter. 
 
 .'i. .-X clear conception of the direction and changes of direction of 
 the esophageal axis as herein given. 
 
 4. A good general sense of direction that enables the endoscopist 
 to point his esophagoscope in the general direction of the esophagus. 
 
 •"). -^ clear mental image of the esophagus and its direction in re- 
 lation to the esophagosco])e. 
 
 \\ ith these (jualifications the endoscojiist has onl)- to follow the 
 landmarks, to be able (juickly to ])ass the esophagoscope on any human 
 being whose mouth can he o[)ened. The introduction may be divided 
 into four stages. 
 
 1. ICntering the right pyritorm sinus. 
 
 2. Passing the cricopharyngeus. 
 
 ■i Passing through the thoracic esophagus. 
 1. Passing the hiatus.
 
 188 INTRODUCTIOX OF TtlE ESOPHAGOSCOPE. 
 
 During the entire iirocedure the patient and second assistant are 
 in the Boyce position (Fig. 73), the second assistant holding the bite 
 block. During the first and second and third stages the head is held 
 high, in the fourth stage it is dropped until the occiput is slightly below 
 the level of the table. Hence, the author has for convenience formed the 
 habit of calling his method the "high-low" method of esophagoscopy. 
 
 Stage i. Entering the pyriform sinus is readily understood by look- 
 ing at the schema, Fig. 147, and comparing it with Fig. 1, Plate III. The 
 collar of the tube is held lightly between the right thumb and fingers as 
 shown in Fig. B. 138, and the tube-mouth, guided by the left hand, is in- 
 serted posterior to the dorsum of the tongue and with the proximal end 
 high (Fig. 148).* The operator standing, his eye at the proximal tube- 
 mouth seeks the right pyriform sinus. (P. Fig. 147, and Fig. 2, Plate 
 III). The landmark is the right arytenoid eminence. A, Fig. 147, which 
 
 Fig. 147. — Schema for finding the pyriform sinus in the author's method of 
 esophagoscopy. The large circle represents the cricoid cartilage. G, glottic chink, 
 spasmodically closed. VB, ventricular hand. A, right arytenoid eminence. P, right 
 pyriform sinus, through which the tube is passed in the recumbent posture. (Com- 
 pare Fig. I, Plate III.) The pyriform sinuses are the normal food passages. 
 
 shows as a rounded mass rather larger than when seen by the indirect 
 method. (Seen upward to the left in Fig. 2, Plate III). Great care must 
 be taken to identify this arytenoid and to avoid hooking the tube-mouth 
 over it or its fellow. This would prevent further insertion and if force 
 were used the arytenoid inobility might be seriously injured. (A, Fig. 
 153). Having found the right pvriform sinus the tube glides in readily 
 for 2 or 3 centimeters when it comes to a full stop and the luiuen dis- 
 appears. This is the spasmodically closed cricophar\ngeal constriction. 
 Buying stage i or any of the other stages the fingers are not inserted in 
 the mouth, e.veept to far as neecssarx for the "hool^inc/" of tlie plialanges. 
 (Fig. 137). 
 
 Stage 2. Passing the cricopharyngeus is, with the beginner, the 
 most difficult part of esophagoscopy, especially if the patient is unanes- 
 
 *In passing the slanted-enti esophagoscope (Pig:. 426) in the recumbent pa- 
 tient, the handle of the e.«ophagoscope must always point toward the ceiling, in 
 order to bring the lip of the esophagoscopic tube-mouth anteriorly, so as to ride 
 over the cricopharyngeal fold. If the lip is posteriorward. perforation is possible 
 if violence be u.sed.
 
 INTKODUCTIOX OI" THE KSOPII AGOSCOPE. 
 
 189 
 
 thutized. Local anesthesia does not help much. The cricopharyngeus as 
 seen through the esopiiagoscope does not resemble the image seen in the 
 speculum (Fig. 3. Plate III). It is simply a lost lumen. Only a solid 
 wall of mucosa is seen. Force must not be used but a steady, firm pres- 
 sure is made on the esophagoscope while a strongly anterior (lifting in 
 the recumbent position ) movement is imparted to the distal end of the 
 esophagoscope by the left harid. At the same time the lifting motion is 
 imjiarted. the distal end should be guided slightly toward the middle 
 
 Fig. 148. — Esophagoscopy by the author's high-low method. First stage. Find- 
 ing the right pyriform sinus. In this and the second stage the patient's vertex is 
 ahoul 15 cm. above the level of tlie tabic and in full extension. 
 
 line of the body. If the lumen is not seen, Ihc [)alicnt siuiuld lie told to 
 take a (lcc|i brealh when the lunun will tisualK- ajipear. In an unanesthe- 
 tized child the deep inspiration will soon be made involuntarily. A little 
 patience here will always succeed. The author's slanted-end esoiihagoscope 
 executes this second stage with particular ease, the lip being insinuated 
 upward and forward, and the handle being held sagittaliy and anteriorly. 
 The lumen is a mere slit, like Fig. 4, Plate 111, though the axis 
 of the slit may be in other directions. The folds at the sides of the slit 
 may seem to bulge toward the operator. In manv instances it is roselte- 
 like in form with radial folds; and it varies with the instrument used.
 
 190 
 
 INTRODUCTION OF THE ESOPHAC.OSCOPE. 
 
 There is usually from 1 to :! cm. of this constricted lumen at the level of 
 the cricopharyngeus and the subjacent orbicular esophageal fibers, after 
 which the esophagoscope glides into the few centimeters of partially open 
 cervical esophagus. (Fig. 5, Plate III). 
 
 Stage j. The esophagoscope usually glides easily through the thor- 
 acic esophagus (Fig. 150). If it does not the patient's position is faulty 
 or the esophagoscope is rubbing on the upper teeth. The levels of the 
 aorta and left bronchus (Fig. 6, Plate III) are readily recognized by the 
 description previously given. After passing them the lumen of the eso- 
 phagus seems to have more and more of a tendency to disappear an- 
 teriorly. This is the signal for lowering the head, which has till now 
 been kept high, for the next stage. 
 
 NECK. 
 
 Fig. 149. — Schematic illustration of the author's "high-low" method o£ esoph- 
 agoscopy. In the first and second stages the patient's head fully extended is held 
 high so as to bring it in line with the thoracic esophagus, as shown above. The 
 Rose position is shown by way of accentuation. 
 
 Stage 4. Passing the hiatus is very easy after a little practice if the 
 directions here given are followed. It will be remembered that in the 
 first part of this chapter the direction of the lower esophagus was given 
 as anteriorly and to the left. To obtain this in the recumbent patient 
 the head is dropped as shown in Figs, l")! and l'^'i. 
 
 When the head is dropped it must at the same time be horizontally 
 moved to the right (withotit rotation) in order that the axis of the eso- 
 phagoscope shall correspond to the axis of the lower third of the eso- 
 phagus which deviates to the left. The shoulders should also 
 participate slightly in this movement. It is in the facility of making these 
 movements that one of the great advantages of the Boyce position over 
 the lateral or any other position for esophagoscopy consists ; and had the 
 author not had the advantage of "team work"' with a good assistant hold- 
 ing the patient in the Boyce position he could not have developed this 
 "high-low" method to its present approximate perfection. This dropping
 
 iNTRonrcTioN oi" Tin-; ksopiiacoscopk. 
 
 191 
 
 of the head was not uiulcrslood hy Alikuhcz ami in order to overcome the 
 angle P S, Fig. 152, he put a htnd in his gastroscope thinking that he 
 had encountered the dorsal spine when his tube, which was passed blind- 
 ly, encountered the resistance of the diaphragm, against which the esoph- 
 agus was pushed just above the hiatus, because the direction of the tube 
 was faulty owing to not dropping the head. Mikulicz did not use the 
 dorsal position but doubtless he would have obtained an equivalent of 
 
 Fig. 150. — Esophagoscopy by the author's "high-low" method. Stage ,?. Pass- 
 ing thrcjiigh the thoracic esophagus. 
 
 dropping the head had he been possessed of a modern o]>en tube gas- 
 troscope passed by sight. The hiatal constriction may assume the form 
 of a slit or more commonly a rosette (Fig. 7, Plate III), and in its ro- 
 sette form has often been mistaken by esophagoscopists for the cardia, 
 leading to the erroneous idea of a sphincter at the cardia. If the ro- 
 sette or slit cannot be promptly found, as may be the case in various de- 
 grees of diffuse dilatation, the tube-mouth must be shifted farther to the 
 left, and also anteriorly. I f the tube-mouth is centered over the hiatal 
 constriction, moderately linn i)ressure continued for a short time will 
 cause it to yield. Then the tube, maintaining its same direction will,
 
 192 
 
 INTRODUCTION OF THE ESOPHAGOSCOPE. 
 
 witlKHit further trouble, glide into and through the abdominal esophagus. 
 The cardia will not be noticed as a constriction, but its appearance will 
 be announced by the rolling in of reddish gastric, mucosal folds, Fig. 8, 
 Plate III, and by a gush of fluid from the stomach. 
 
 The normal esophagoscopic image. The form of the endoscopic 
 image has already been described, as seen at the various stages of esoph- 
 agoscopy. The color, as in all the mucosae, is subject to wide individ- 
 ual variations within the limits of health, though not, perhaps, quite so 
 wide as is seen in the phar\nx. The color, of course, varies in shade 
 
 Fig. 151. — Esophagoscopy by the author's "hii;h-lii\v" nu-thod. Stage 4. Pass- 
 ing the hiatus. The patient's vertex is about 5 cm. below tlie top of the table. 
 
 with the intensity of the illumination, being dark criinson or brown un- 
 der feeble light, nearly white under the intense light of an over-illumi- 
 nated electric lamp. L'nder ordinary conditions with proper illumina- 
 tion it may be described as pink varying from yellowish to bluish pink. 
 As the author has pointed out, a good idea of average color may be had 
 from inspection of the inside of the particular individual's cheek under 
 the same illumination. The esophageal mucosa glistens with surface 
 moisture. The folds are soft and velvety, rendering infiltrations quickly 
 noticeable. The cricoid cartilage usually shows whitish through the mu- 
 cosa. As soon as the eye becomes educated to the normal appearance
 
 iNTKonrcTioN (II" Till-: i:sopiiagoscope. 
 
 193 
 
 abnormalities of form and color are instantly noted. The gastric mu- 
 cosa is pink if no food is present, but it is a darker pink than that of 
 the esophagus. When food is in the stomach the color is crimson. These 
 colors refer to distally illuminated images. With proximal illumination 
 the color is said to be dark \ioIet. probably because of the distance from 
 the source of light. 
 
 Difficulties of esof'luigoscof'y. Those who follow carefully the meth- 
 ods herein suggested should be able to esophagoscope an average patient 
 under general anesthesia. For the first trial of esophagoscopy without 
 anesthesia the patient should be a slender adult, with long lean neck and 
 lew upper teeth. The author urges every endoscopist to avail himself 
 of the first esophageal case of this type, to try esophagosco[)y without 
 anesthesia. Soon be will find it needless to use either general or local 
 
 Fig. i-,2. — Srliematic illustration of the aiithor'.s "high-low" method of esoph- 
 agoscopy, fourth stage. Passing the hiatus. Tlie head is dropped from tlie po- 
 sition of tlie I St and 2nd stages, CL, to the position T, and at the same time the 
 head and and shonklcrs are moved to the right (without rotation) wliich gives the 
 necessary direction for passing the hiatus. 
 
 ane.ilbesia for esophagoscoiJN , and be will have many occasions to be 
 glad that he has ac(|uired the knack. Cases of esophageal malignancy 
 quite often present the desired qualities mentioned, and many of them 
 come for diagnosis in no c(jndition to stand an anesthetic. The greatest 
 difficulty arises from the faulty direction of the tube. It requires a gen- 
 eral sense of direction and a mental picture of the direction of the esojjb- 
 agus within the body ti> get ibe lube started right and to find the lumen 
 of the pyriform sinus ami of the eso])bagus until the operator bas had 
 sufficient experience to know the landmarks and tlie diflerent appear- 
 ance of the folds of niuciisa as be proceeds. In order tn bring these
 
 194 INTRODUCTION OF THE ESOPHAGOSCOPE. 
 
 into view it is necessary to remove the secretion. In the author's esoph- 
 agoscope this is taken away with the aspirator without interruption, 
 though occasionally a swab may be useful in addition. Stagnant semi- 
 solid food in stenotic cases is best removed by the "sponge pumping" pro- 
 cess as described for bronchoscopy. Another great difficulty arises from 
 the spasmodic contractions of the esophageal musculature and especially 
 of the inferior constrictor near the cricoid level, in fact, the greatest 
 difficulty in esophagoscopy is right at this point. This and the hiatal 
 spasm are to be overcome by patient waiting with gentle pressure on a 
 correctly directed tube centered over the closed lumen. Forcible misdi- 
 rected pressure may perforate. The beginner will often find that the 
 esophagoscope seems to be rigidly fixed so that it cannot be either in- 
 troduced or withdrawn readily. Usually this comes from contact with 
 the upper teeth of the patient and is overcome sometimes by a little wider 
 opening of the jaws, and sometimes by easing up on the bite block, but 
 most often by correcting the position of the patient's head. If the be- 
 ginner cannot start the tube into the right pyriform sinus, in an adult, 
 it is a good plan to insert an adult direct larj-ngoscope, and after expos- 
 ing the arytenoid eminences to view to insert the child size (7 mm.) 
 esophagoscope into the pyriform sinus by sight. This is one of the best 
 ways to learn esophagoscopy. The side-slide oval laryngoscope is the 
 best for this purpose, leaving the slide ofi" and keeping the speculum to 
 the right (recumbent patient) side of the tongue so that the tongue will 
 not crowd into the side opening. It is very rarely necessary to remove an 
 esophagoscope once it is inserted. The author has been much surprised 
 to learn how often some esophagoscopists remove and reinsert the esoph- 
 agoscope at a seance. Once in. it should stay until the esophagoscopy 
 is finished. If an anesthetic is used, it may be necessary to remove the 
 esophagoscope for respiratory arrest, unless insufflation anesthesia is 
 used. Without anesthesia no accident can occur in careful hands. Oc- 
 casionally it is necessarv' to remove the esophagoscope to exchange it for 
 a very small one that will go through a small stricture to get a foreign 
 body that has lodged between two strictures. Occasionally, especially in 
 stenotic conditions of the esophagus a large quantity of fluid will well up 
 into the tube and it will be thought that the light has gone out because 
 there are a number of centimeters' depth of opaque fluid over the light. 
 As soon as this is aspirated through the drainage canal the Hglit will be 
 found burning as brightly as ever. If in doubt as to whether this is the 
 case the light carrier may be withdrawn, but under no circumstances 
 except vital dangers to the patient should the esophagoscope be with- 
 drawn until the examination is complete. As the author uses only two 
 sizes of the esophagoscopic tubes, one for adults and one for children.
 
 IXTKODUCTION OF TIIIC ESOPll AGOSCOPE. 195 
 
 there is no need of starting with the wrong size. Serious difficulties may 
 arise from insutticient instrumental e(|uipment, and unlike other depart- 
 ments of surgery makeshifts are usually impossible and may be dangerous. 
 Xo peroral endoscojiic attempt should be made without proper sized 
 tubes for the particular case, i)roper forceps, sponges, batteries, etc. The 
 operator does his patient and himself an injustice to attemiil endoscopy 
 without a complete set as to sizes of whatever form of tubes he desires to 
 use. In his earlier writings the author stated that "If rigid economy 
 must he ])racticed, much good work can be done with a 7 mm.x4."j cm. 
 esophagoscope, a ■'> mm.x30 cm. bronchoscope and a 12 mm.xlT cm. 
 laryngeal speculum." Bninings has very justly criticized this statement 
 as "likely to beguile the surgeon" into being content with a couple of 
 tubes selected at random ; and he further states, "An insufficient equip- 
 ment is often worse than none at all.'' In all of which the author fully 
 concurs. 
 
 Moser has advocated the ballooning of the esophagus by the soft- 
 rubber hand-ball of an atomizer, the air being prevented from escaping 
 by the insertion of the window-plug (Fig. 20). 
 
 In conclusion it may be said that with the exception of inadequate 
 ecjuipment all of the difficulties of the introduction of the esophagoscope 
 are overcome, as with any other (nirely manual procedure, bv practice. 
 
 Complications following csophagoscopx for foreign bodies will be 
 considerefl in a later chapter. The simple passage of an esophagoscope, 
 if skillfully done, is rarely, if e\er, followed by any complications. Slight 
 stiffness of the neck, an<l irritation of the lower pharynx may be noted 
 in sensitive subjects, especially those with siiorl, thick necks. In dis- 
 eased conditions, however, we may have complications due either to the 
 esophagoscopy or to the condition for which it is done. Mr. W'aggette 
 (Bib. 5()7) rei)orts a case of severe dysfjhagia following esophagoscopy 
 in a case of extensive specific ulceration. It would seem, however, that 
 the dysphagia might have resulted from the disease itself willmut ilic 
 esophagoscopy. Roth contingencies should be borne in mind, and a pa- 
 tient with disease of the esophagus should tie lold l)eforeliand that his 
 ability to swallow may grow worse either with nr witln'iu an esophagos- 
 copy. These remarks, howe\fr. do not ordinarilv apply to recent foreign- 
 body cases, (lid foreign-body cases may be followed by cicatricial 
 stenosis. If esophagoscopy is to maintain the high position of usefulness 
 it has attained it is necessary that it shall be safe. If the rules and in- 
 structions herein given are followed, esophagoscopy is absolutely without 
 mortality aj^art from the condition for which it is done. In view of this 
 tile beginner must be warned to be careful. The accidents shown in 
 r'ig. 1"):! can occur only through brutal disregard for the delicacy of the
 
 196 INTRC)DrCTIC)X 01- THK KSOPHAr.OSCOPlC. 
 
 esophageal structures. The esophagus is surgically the most intolerant 
 organ in the hody. It will not tolerate anything like the degree of oper- 
 ative work that even the brain can stand. This, of course, is partly due 
 to the fact that the esophagus is a septic canal, but apart from sepsis, as 
 explained in the second part of this book, the esophagus is, surgically, 
 intolerant. 
 
 Injury to the cricoarytenoid joint (A. Fig. !')'.'> ) from hooking of 
 the tube-mouth over the arytenoid eminence may simulate recurrent 
 paralysis. It is usually due to traumatic arthritis or myositis. Posticus 
 paralysis may occur from recurrent or vagal pressure by a misdirected 
 esophagoscope. Both fixation and paralysis usually recover, but occa- 
 sionally persist. Perforation of the esophageal wall and false passage 
 has already been alluded to. In some instances fatal septic mediastinitis 
 
 i^ 
 
 Fig. 153. — Injuru's truin iorciijle unskilled attempts at usuijhagoscupy. A. 
 Fixed right arytenoid injured by the mouth of the esophagoscope. View through 
 direct laryngoscope. Recovery followed. B. Opening of false passage just above 
 the mouth of the esophagus at the site where diverticula occur. Fatal. C. Extrav- 
 asated blood under the mucosal epithelium simulating a varicosity or angioma. 
 Caused by undue pressure of the tube mouth. Probably not serious but indicative 
 of a dangerous amount of force. D. Exudate covering long, gouged area resulting 
 from unskillful esopha.goscopy. Profound shock. Death from sloiigliing sopha- 
 gitis. (Sketched by the author from cases seen in consultation.) 
 
 has occurred. In some cases which have come to the author's knowledge, 
 ])erforation of the pleura has occurred. In all such instances, the au- 
 thor would advise immediate opening and drainage of the pleura. Pletiral 
 shock is already ]:)resent. usually pneumothorax also. All such cases de- 
 velop a initrid discharge, having the odor of fecal matter, with profound 
 sepsis, irritability and high fever unless drained promptly. In case of 
 septic mediastinitis, the general surgeon should be consulted, though un- 
 fortunately most cases are hopeless. 
 
 A frequent accident with the beginner is the gouging of a bit of 
 mucosa from the posterior hypopharyngeal wall. This comes from one 
 or more of three errors: (1) Faulty position of patient, (2) faulty di- 
 rection of the tube, and (3) undue haste to advance the tube instead of 
 waiting for the stihsidence of cricopharyngeal spasm. Patients with ad-
 
 INTRODTTIION Ol- i' 1 1 1: ICSOIMI Ai'DSCOPK. 197 
 
 vaiiced organic disease such as hard arteries, cirrhosis of the Hver, ad- 
 vanced tuberculosis, uncompensated heart lesions, etc., may have se- 
 vere complications precipitated by esophagoscopy. A child's esophago- 
 scope ( 7 mm. ) skillfully passed with high head will involve the least 
 risk in such cases. 
 
 J'lic tcclniic of introduciiui the Kahler csophagoscopc is precisely 
 the same as that of the Hriinings esophagoscope. 
 
 Introduction of the Brnnings esophagoscope. Britnings describes 
 two methods of introduction, one with a mandrin and one without, the 
 former the easier, the latter the preferable way, Briinings advises 
 ocidar introduction when mandrin introduction involves special dangers 
 or fails to accomplish the object for which the esophagoscopy is done. 
 He believes that ocular introduction, therefore, is indicated in the ma- 
 jority of cases. Itninings ])refers the sitting position of the patient, 
 though he also uses the laterally recumbent position with knees flexed. 
 In either position the patient's head is held by an assistant. Occasionally 
 he uses the dorsally recumbent position, but he regards this as more 
 difficult, and in children he states that "Lying on the back must in any 
 case be avoided." He states that a general anesthetic is always neces- 
 sary in children and that they must be raised up for the introduction 
 of the tube after they are anesthetized. In adults thorough local anes- 
 thetization with cocaine is used. The ISrunings tubes should be warmed 
 and greased with licjuid petrolatum and the mirror shoidd be warmed 
 to prevent fogging from condensation. In introduction of the esophago- 
 scope with the mandrin, the hand lamp. Fig. 2. is detached ; the funnel- 
 shajied [jroximal end of the tube is held between the thumb and linger 
 of the right hand like a ])en. The silk wo\en mandrin projecting be- 
 yond the distal end of the tube is ])assed down along the posterior 
 pharyngeal wall into the esophagus. If the mandrin deviates into either 
 pyriform sinus, Briinings directs the patient to swallow to centralize the 
 tube again. When the reflex contractions at the esophageal mouth stop 
 the advance of the mandrin and instrument, no violence is to be used. 
 Instead, an in-and-out ])rol>ing niovenient of the tube is used and llie 
 patient is commanded to continue regular breatiiing. and to swallow. If 
 introduction fail, it is necessary to wait with the tube and mandrin in 
 position until the spasm relaxes. This is known by the sensation of an 
 easy advancing of the tube to slight pressure, and by the fact that the 
 "spatula tube" of the inslnmient almost (lisai)i)ears in the moiuh. Then 
 the [jatient bends the head farther backward and the itroximal portion 
 of the tube is moved around to one corner of the patient's mouth, the 
 head being slightly turned to the o])posite side. If a gap between teetli 
 is available the tube is moved into the gap. Then the mandrin is re-
 
 198 INTRODUCTION OF THE ESOPHAGOSCOPE. 
 
 moved, the hand lamp attached and the inner tube inserted. If the latter 
 has been in place with the mandrin inside of it, it is now pushed down- 
 ward. In most instances, however, foreign bodies and disease high up 
 are dealt with through the spatula tube alone, without using an inner 
 tube. 
 
 In introduction by sight in the sitting patient the procedure is as 
 described for direct laryngoscopy up to the point of exposing the larynx, 
 the hand lamp being fitted with the tube spatula as shown in Fig. 2. 
 This will reach to the level of the tracheal bifurcation. If it is desired 
 to explore further, the inner tube ( Fig. 4 ) of appropriate size and length 
 according to the patient is inserted. After exposing the larynx, the 
 spatular end of the tube spatula, or outer tube, is inserted in the median 
 line and the larynx is drawn forward as the spatular end is slid down 
 behind the larynx into the hypopharynx. Here the advance is usually 
 opposed by spasm, bringing the posterior lip of the esophageal mouth 
 forward and presenting an "unconquerable barrier" to further advance. 
 While waiting for the spasm to subside the position of the patient and 
 of the instrument are inspected to see that they are correct, with relaxed 
 muscles, without rigid bending of the head ; and the patient is told to 
 keep on breathing quietly and regularly. Swallowing, if the patient can 
 accomplish it. helps materially. Rotating movements of the tube are 
 helpful in finding the lumen. Once past the constriction at the mouth of 
 the esophagus the tube passes without further difficulty, the head being 
 managed as before. When the full length of the spatular tube, or outer 
 tube, has been inserted, which will bring the distal end to about the 
 level of the tracheal bifurcation, the inner extension tube is inserted if 
 it is desired to explore further. In the left laterally recumbent patient 
 the manipulations are the same as in the sitting patient, because with the 
 operator standing facing the patient, and bending the operator's head 
 down to the right, the operator maintains the same relative position to 
 the patient's anatomy as in the sitting position of the patient. In the 
 dorsal position of the patient which Briinings does not advise, the oper- 
 ator holds the instnmient with the right hand as in Fig. 142. For fur- 
 ther details of Briinings' methods the reader is referred to Briinings' in- 
 teresting and instructive book (Bib. 62) or to the excellent translation 
 thereof by Mr. Walter G. Howarth (Bib. 208).
 
 CHAPTER XI. 
 
 Acquiring Skill. 
 
 The purpose of this book is to tell how to do peroral endoscopy. 
 But with all purely manual things a knowledge how to do them is mere- 
 ly a start. It requires prolonged practice to be able to do them well. 
 An orchestra leader knows how the instruments should be played, yet is. 
 unable to play upon any except the one on which he has spent a lifetime 
 of practice. Were it not for the evidence of the performance of others, 
 a beginner's first instrumental musical attempt would lead him to think 
 impossible many of the manual things that later are as easy to him as 
 walking. Other and new difficulties will arise and will be overcome ; 
 there will always be difficulties worthy of continual practice in order to 
 acquire the utmost tactile and co-ordinate dexterity. So it is with peroral 
 endoscopy. Herbert Tilley (Bib. 545) very aptly states that, "While it 
 would be idle affectation to suggest that neither skill nor practice is ne- 
 cessary for the intelligent use of the bronchoscope, yet it is very true 
 that a little practice combined with patience and gentleness should ren- 
 der any surgeon comiictent to use the bronchoscope with reasonable as- 
 surance." W hile the author believes that more than a little practice is 
 desirable, he heartily concurs in the foregoing statement because of the 
 qualifying clause "'combined with patience and gentleness." These are 
 the great safeguards of endoscopy. 
 
 As with instrumental music certain personal qualifications will en- 
 able better endoscopic work and especially is this true in diflicult foreign- 
 body cases. Good eyesight without excessive refractive errors comes 
 first in imjiortance. Endless patience is an essential. A good faculty of 
 orientation will stand the endoscopist in good stead. Mechanical in- 
 genuity is necessary. The greatest percentage of successes will accrue 
 to him who is so constituted as to work calmly and deliberately, yet 
 quickly and accurately, under severe stress of ])rolonged work with one 
 eye, subject to great anxieties and where a mistake or lack of prompt- 
 ness and accuracy may mean the flcath of the ])aticnt either immediately 
 or by default ultimately. There is absolutely nothing like it in the whole 
 realm of surgery. The operator's ordeal is well described by Ingals as
 
 200 ACgilRING SKILL. 
 
 folluws: "'riie heart-breaking delays, the extreme anxiety for the pa- 
 tient and the knowledge that jjrolonged operations of this kind are dan- 
 gerons, while failure may spell death for the patient, place the operator 
 under such circumstances under an indescribable stress.'' 
 
 The greatest difficulty will be encountered by the surgeon who has 
 been accustomed always to work with both hands and both eyes in an 
 open wound. Such a one will tind difficulties in working with the mirror 
 in ordinary indirect rhino-laryngologic work, and endoscopy will ])re- 
 sent to him difficulties infinitely greater. Far be it from the author to 
 deter any one from taking up bronchoscopy and esophagoscopy. On the 
 contrary, it has been the author's endeavor for years to popularize these 
 procedures with the jirofession and to induce every one who is willing 
 to devote to it the necessary amount of practice, to take it up. In fact 
 it is because the author once said that bronchoscopy and esophagoscopy 
 were easy, that he deems it at this late day necessary to issue a word 
 of caution against taking up the work, especially in foreign body cases, 
 without due appreciation of the difficulties to be met and overcome only 
 by continual practice. 
 
 The foregoing, however, applies only to foreign body work, direct 
 lan'ngeal operating, and a few other procedures like the dilatation of 
 bronchial and esophageal strictures, exploration of the subdiverticular 
 esophagus, and the like. It does not apply to the exposure of the larynx 
 for diagnosis or for the introduction of intratracheal insufflation tubes, 
 which procedures anyone can easily learn without special forehead mir- 
 ror experience or special qualifications. The author believes that every 
 laryngologist of the future will be considered incompetent if he cannot 
 examine the larynx of any child by direct laryngoscopy, and that the 
 rhino-laryiigologist (who of necessity is trained by years of work with 
 one eye through narrow o])enings ) is, logically, the best man fitted for 
 bronchoscopy and esophagoscopy, and he should be a bronchoscopist and 
 an esophagoscopist. If, however, the laryngologist prefers not to de- 
 vote the time and attention needed to do them well, he may refer cases 
 requiring bronchoscopy and esophagoscopy to some near neighbor who 
 is equipped: but escape direct laryngoscopy he cannot, if he desires to 
 be called a laryngologist.* It is the author's hope and belief that per- 
 fection in direct laryngoscopy will lead every rhino-larjngologist pos- 
 sessed of good eyesight to be also a broncho-esophagoscopist. For 
 foreign-bodv work a large instrumental outfit is necessary, but no arma- 
 mentarium, however complete, will lessen the need for prolonged co- 
 ordinate education of the eye and the fingers. To some extent, this 
 might be said of surgeiy in general ; but with endoscopy it will be very 
 different if none of the ])revious training of the surgeon has been in the 
 
 •Extracted frum the -Vuthor'.s "l!a|)i)ui t" at tlu- International Medical C'on- 
 eress, London. 1913.
 
 AforiKINC. SKIM.. 201 
 
 line of working with one eye while ij,nioriny the image of the other, nor 
 in the jiracticc of depth jierception with one eye only. Estimation of 
 distances is under all circumstances largely a matter of personal e(|ua- 
 tion, some persons being remarkably adept naturally, wdiile others find 
 it exceedingly difficult to make even an approximate estimate of so ap- 
 parent a distance as the width of a street. Such difficulties in making 
 estimates are, of course, enormously increased when they are to be 
 made with one eye only and looking through a tube. Much practice, 
 howe\er, will enable anyone to estimate with sutTicient accuracy the va- 
 rious depths of the tissues seen in the endoscopic image; and those with 
 natural aptitude can develop this depth perception to an extent that 
 seems incredible. -Much as it may hurt the self-esteem of the surgeon, 
 after his years of exjjerience in surgery, if he wishes to do bronchoscopy 
 for foreign bodies, he must begin at the beginning and take endless hours 
 of practice on the dog, unless he be so heartless as to do his first tube 
 work on human beings. Practice on human beings in the general field 
 of surgery is very different, because the careful man, working in an ojien 
 wound with both eyes and both hands, and with an experienced surgeon 
 assisting, will do no harm. The very worst that may follow is siinply a 
 prolongation of the operation. In endoscopy, prolongation is often a 
 very serious matter ; and the errors of omission and those of commission 
 may be fatal both by default in not removing the foreign body ; in mak- 
 ing it im])ossible for anybody else to remove it ; or in producing fatal 
 trauma or respiratory arrest. Master and pupil cannot see at the same 
 time in endoscopy. 
 
 Fur the acquirement of skill five modes of education of the eye and 
 fingers are available. 
 
 1. I'reliminary practice with bronchoscope and forceps. 
 
 2. I'ractice upon the cadaver. 
 '.]. I'ractice upon the dog. 
 
 •1, .Sketching the endoscopic image. 
 
 5. I'ractice upon human beings. 
 
 Prcliininary practice. The first step for the beginner in endoscopy 
 should be the mastery of the mechanical details of tubes and their illumi- 
 nation. He should learn just the degree of illumination the lamps will 
 stand without burning them out or shortening their "life." Carbon fila- 
 ment lanijis will stand only an am])erage that is indicated by the filament 
 hct/iiiiiiiK/ to turn white. Tungsten filament lamps illuminate with a less 
 amperage, but the rheostat may be run up until the filament gets (|uite 
 white. Tf after an hour's use the glass of the lamp shows black it in- 
 dicates that the lamp has been overilluminated. Some instruction by an 
 electrician is valuable. These .suggestions apply to all forms of instru- 
 ments. With the I'.ninings and Kahler instruments the adjustment of
 
 202 ACQUIRING SKILL. 
 
 illumination, centering of the light, etc., should always be done as a pre- 
 liminary ; not while the tube is in the patient. With the author's instru- 
 ments if it is desired to inspect the lamp while the endoscopic tube is 
 in the patient, the light carrier may be withdrawn and the lamp replaced 
 or adjusted. With any form of instrument it is a mistake to turn on 
 more current with the tube in the patient every time the field seems in- 
 sufficiently illuminated. The loss of light may be due to soiling or mois- 
 ture condensation on the mirror of handlamps or headlamps, to secretion 
 in the tubes, etc. With the Briinings instrument the manipulation of the 
 reflector should be practiced so that the light may be cjuickly centered. 
 This is accomplished by adjusting the mirror so that the crossing point 
 of the filaments in the image projected onto any vertical plane is seen 
 to be exactly concentric with the center of the tube through which the 
 observer is looking. The swinging aside of the mirror carrier should be 
 practiced because this must be promptly done in anticipation of the pa- 
 tient's every cough to prevent soiling of the mirror. Practice in the 
 left-handed insertion of the inner tube, and in looking through the mir- 
 ror slot is essential to good work. All of the instrumental manipulations 
 above referred to can be as well learned on inanimate objects an on a 
 patient. The Kirstein headlamp as used by Killian, and the Claar 
 headlight as used by Guisez re(|uire focusing and adjustment to insure 
 parallelism between the visual and illuminant axes, which will not be 
 difficult for the laryngologist. who, of course, is accustomed to work with 
 head mirrors and headlights. The Kirstein and Claar headlights may, 
 indeed, be used with great advantage in nasal and indirect laryngeal 
 work. The next step is preliminary practice with bronchoscope and 
 forceps in picking up threads from a table. The small bronchoscope 
 (.J mm.) should be used and the forceps should never be closed except 
 under guidance of the eye at the proximal tube-mouth. First, short bits 
 of black threads on a white cloth should be used : then white threads on 
 a white cloth, finally black threads on a black cloth. Incidentally it may 
 be mentioned that this thread practice is an excellent method of testing 
 the different form of instruments and illumination in order to select the 
 kind best suited to the operator's personal ecjualion. Comparisons should 
 be with tubes of equal diameters. 
 
 The conscientious beginner will engage in preliminary practice un- 
 til all of the manipulations are automatic. 
 
 Practice on the cadaz'er is very useful for the study of tlie local 
 anatomy because there are no reflexes or secretions to hinder. Anyone 
 can fumble around until he succeeds in exposing the cadaveric larynx 
 and introducing the bronchoscope or esophagoscope ; but this is not the 
 best method of study. The influence of position should be carefully 
 noted by lowering the head to the Rose position. Then the direct laryngo-
 
 ACQUIRING SKILL. 203 
 
 scope should be introduced and the fully extended head gradually raised 
 until the vertex is higher than the table. The laryngeal exposure ob- 
 tained will give the key to the proper position for peroral endoscopy. 
 Then the bronchoscopic and esophagoscopic anatomy should be studied. 
 Particular attention should be given to appreciation of distances especial- 
 ly those from the glottis to the bifurcation ; from the bifurcation to the 
 upper lobe bronchi on the right and the left sides respectively ; and from 
 the right upper-lobe bronchus to the middle-lobe bronchus. The angle of 
 branching of the larger bronchi is also important, though these angles are 
 apt to be distorted in the cadaver. The beginner in endoscopy should make 
 himself familiar with all parts of the tracheo-bronchial tree so that he 
 knows instinctively how to reach any desired location. All of these 
 things can be learned quicker and better on the cadaver than on the 
 living and they cannot be learned at all from books. 
 
 Practice upon the dog. The next step in the endoscopist's training 
 should be the education of the eye to the prompt comprehension of the 
 endoscopic pictures by practice upon the dog. This will be of little use 
 so far as the exposure of the larynx and the introduction of the broncho- 
 scope and esophagoscope in the human being are concerned, because 
 the dog does not jM-esent the difficulties arising in the human being from 
 the right-angled pharyngeal turn of the air and food passages. Never- 
 thelesS; practice on the dog is of the utmost importance in training the eye 
 and the fingers. The mentality of vision must be educated not only to 
 comjjrehend the endoscopic image but it must comprehend the ever chang- 
 ing image jiromptly. The histologist must educate his eye to extreme 
 niceties of morphologic distinctions, but he has no end of time in which 
 to study each field. The endoscopist in making observations in the air 
 and food passages must observe not only form but color; and most ditti- 
 cult of all. his object is never still a moment, never twice in precisely the 
 same position. 
 
 It takes much practice to be sure when the forceps are at the proper 
 depth to grasp the foreign body or particular piece of tissue. Dog work 
 is better than cadaver work for practice in this direction, because the 
 colors, and especially the constant respiratory, ])ulsatory, bechic, and, 
 in case of the esophagus, peristaltic and antiperistaltic movements present 
 actual working conditions. Xo one should think of attempting for 
 the first time to remove a foreign body from a human being until he has 
 at least H>0 times removed a foreign body from a dog. If the operator 
 has jjul little endoscopic work to do, he should practice between times on 
 the dog in order to maintain skill. In foreign body practice on the dog, 
 it is well to remember that this animal is peculiarly well able to rid him- 
 self of foreign bodies. He can get open safety-pins and sometimes even 
 fish-hooks out of his bronchi. .Manv letters of chagrin have come to the
 
 204 ACQUIRING SKILL. 
 
 author relating inability to find foreign bodies introduced a day or two 
 before. If for any experimental purpose it is desired to have a foreign 
 body remain in the canine lower air passages, it is necessary to devise a 
 very secure anchorage. A small dog is preferable. Large dogs require 
 longer instruments than human beings. Scopolomine 0.00065 gm. with 
 morphine 0.0324 gm. hypodermatically is a convenient anesthetic for a 
 small dog. It should be given an hour in advance and repeated, if neces- 
 sary. 
 
 Sketching the endoscopic image. One of the best ways to educate 
 the eye to grasp (juickly the fleeting panoramic endoscopic views is to 
 practice sketching. However crude, artistically, the effort may be, the 
 practice of quickly observing form and color of the visible field will be 
 of inestimable value. Practice catching the darks first and jot them 
 down with pencil in previously scribed circles. After the habit of quick- 
 ly noting the darks is formed, the noting of the lights as to their form 
 is easily ac(|uired. for m a measure, the lights take care of themseKes 
 because they are necessarily blocked out by the darks. The noting of 
 the color comes next. The color of the darks is unimportant for train- 
 ing of the eye. though, of course, very necessary for accurate illustra- 
 tion. For the recognition of disease it is necessarv to observe the color 
 of the well-illuminated parts — the lights. If the sketching method of 
 educating the eye as here outlined is practiced, it is remarkable how the 
 eye will acquire the habit of quickly recording successive pictures of 
 form and color. .\s the field of view is small the form and position of 
 the darks and the color of the lights are taken in over different parts of 
 tiie whole field simultaneously. If desired, pencil and sketch cards with 
 scribed circles can be sterilized in alcohol for use on the instrument table, 
 but it is scarcely justifiable to keep a patient endoscoped either with or 
 without an anesthetic. Moreover, it is quite unnecessary, because, if the 
 essential amount of endoscopic practice on the dog is done, the sketch- 
 ing can be there practiced until not only will the education of the eye 
 be perfected, but the mental habit of recording impressions will be ac- 
 quired, so that a series of a half dozen or more pictures can be sketched 
 from memory immediately after the endoscopy is finished. Unless one 
 has had much previous training in water or oil colors, wax crayon pen- 
 cils are best, as thev do not require a fixative like pastels, though their 
 tints are not quite so accurate or so easily blended or overworked. Faber 
 makes (iO dift'erent tints under the name of "Castex Polychrome" pencils. 
 Numbers 31, 34, 30, 'M . in and -"i".; will probably be found most useful. 
 P.lending can be done with a clean, pointed pencil-eraser. So far, no 
 ]ihotographic method of recording endoscopic views of the air and food 
 passages has yielded very satisfactory results, not only because of the 
 feebleness and reddish tint of the return ravs, but mainlv l)ecause of the
 
 ACQUIRING SKlI.l,. 205 
 
 perpetual mo\cnieiU which prevents lengthy exposure. L'ntil some diffi- 
 cult problems are overcome, jjencil, crayon and brush are the only means 
 of recording a])pearances. 
 
 Practice upon hujiian bciHi/s. It is stated above that dog and cada- 
 ver i)ractice do not help greath- in overcoming the difficulties of introduc- 
 tion. Dog and cadaver practice do help to some extent, because the 
 education of the eye promptly to appreciate the endoscopic image is 
 fundamental : but the knack of displacement for laryngeal exposure and 
 of passing the cricopharyngeus, esophagoscopically. are yet to be learned 
 and for these purposes only the human being will serve. L'ntil human 
 direct laryngoscopy is learned no attempt should be made to do bron- 
 choscopy or esophagoscopy. Respirator}' arrest during the progress of 
 esophagoscopy, or after the withdrawal of the bronchoscope in bronchos- 
 copy, demands that for the safetv of the patient the operator shall be 
 able promptly to expose the laryn.x and insert the bronchoscope for 
 oxygen insufflation. The familiarity with the location of the pyriform 
 sinuses and laryngopharynx under direct view is (|uite essential to esoph- 
 agoscopy. To anyone who is skillful at cx])osing the larynx, the intro- 
 duction of the bronchoscope is easy, and no one should attemj)! bron- 
 choscopy until he has acquired sufficient skill to expose the larynx in 
 almost any patient in 15 seconds. Seldom should it require more than 8 
 seconds. One ought to be able to hold the laryn.x in view long enough 
 for half a dozen men to take a look. Fortunately there is. in all out- 
 jiatient clinics, a goodly percentage of cases that justify direct laryngos- 
 copy. Any patient with laryngeal paralysis of undetermined etiology 
 or any patient with infiltration of the arytenoid re.gion should be ex- 
 amined for disease of the [larty wall, antcriorlw and also down in the 
 hypopharvnx. Certain cases of laryngeal tuberculosis are benefited by 
 the direct application of the galvano-cautcry. ( )ther material that can 
 lie conscientiously used will readih- be fciiind, because direct laryngos- 
 copy in any case not dyspneic. and done under aseptic precautions is 
 harmless. Tracheotomized cases should be regularly and carcfullv tra- 
 cheoscoped for exuberant granulations which may occlude the lube antl 
 cause death. I'j-osions, necrosis of cartilage, edematous areas et cetera, 
 due to ill-titting cannulae are remediable. .\ plan for cure of the stenosis 
 can only in this way be formulated. Such cases should be examined from 
 above and below. Having mastered hy]i()])haryngoscopic and direct 
 laryngeal left-hand exiJosure in the human being, the student who has 
 followed the course here laid out need have no hesitation whatever in 
 attempting bronchoscopy or esophagoscopy in any case where these pro- 
 cedures are not contraiiulicated. The tirst few esophagoscopies should 
 be emaciatcfl adults with few teeth, and, if justifiable, should be general- 
 Iv anesthetized.
 
 CHAPTER XII. 
 
 Foreign Bodies in the Air and Food Passages. 
 
 List of foreign bodies found in air and food passages. It seems to 
 die author a sacrifice of space to list all of the foreign bodies so far 
 found in these passages, since any substance not too large and not soluble 
 may be encountered endoscopically : be that substance from the animal, 
 vegetable or mineral kingdoms, or manufactured therefrom by man. 
 Rather would it seem profitable to classify these substances by the me- 
 chanical problems of their extraction and this will be done in future 
 chapters. It may be well here to classify the sources of foreign bodies. 
 The following classification of Voelcker, quoted by Sir St. Clair Thom- 
 son, (Bib. 539) is comprehensive. 
 
 1. From the mouth — articles of food, bones of meat or fish, fruit 
 stones, peas, beans, shells, seeds, ears of corn, grasses, pieces of wood 
 or coal, coins, buttons, pencils, marbles, toys, broken ]Mpe-stems, pins, 
 needles, nails, tooth-plates, leeches. 
 
 2. From the stomach — vomited food or blood, or the migration of 
 lumbrici or threadworms. 
 
 3. From the lungs — hemoptysis, hydatids. 
 
 4. From the outside — as by penetration of a pin, dart, bullet, or 
 drainage-tube from the neck. 
 
 5. From surgical measures — detached portions of instruments, 
 sprays, brushes, cotton-wool, gauze, sponges, ;mlrum plugs, intubation 
 tubes, broken-of¥ cannulae of tracheotomy tubes, amputated tonsils, ade- 
 noids or other growths and hemorrhage. 
 
 6. Arising in situ — necrosed cartilage, ulcerating sloughs, mem- 
 brane, effused blood. 
 
 7. Penetration from the neighborhood — ulceration or extension of 
 malignant disease from the pleura, thyroid gland, or esophagus, or the 
 penetration of a tuberculous gland from the mediastinum. 
 
 To this list might be added the penetration of a foreign body from 
 the esophagus into the trachea, of which the author has seen two in-
 
 FOREIGN BODIES IX AIR AND 1-OOD PASSAGES 207 
 
 Stances, and the penetration of a foreign body from the tracheo-bron- 
 chial tree into the esophagus of which the author has seen one instance, 
 that of a sharp fragment of bone the point of which was visible in the 
 esophagus, but which was removed liy bronchoscopy from the left bron- 
 chus. 
 
 Prophylaxis. Many of the foreign-body accidents are entirely pre- 
 ventable. If no one put into his mouth anything but food, foreign- 
 body cases would be rare. In the author's collection only about three 
 per cent are proper articles of food and these mostly insufiliciently mas- 
 ticated or cooked. This does not include the foods removed from stric- 
 tured esophagus. .\ much larger percentage are substances normally in 
 food stuffs but not removed before eating, such as bones, shells, hulls 
 and seeds. More care in the preparation of food and in the eating of 
 fruits with large seeds is of first prophylactic importance. Care in the 
 preparation of foods can easily prevent the accidental presence of pins. 
 needles, bits of china and glass, enamelling and solder from utensil's and 
 the like. Tradesmen, such as lathers, carpetmen and upholsterers who 
 carry tacks and nails in their mouths could just as easily have learned 
 in the beginning some less dangerous as w'ell as less filthy method, and 
 apprentices should be so taught. Magazines with automatic feeding 
 mechanisms could easily be devised that would also save time, wdiich latter 
 feature is the only one that would appeal strongly to the employer. Chil- 
 dren should he taught from infancy not to put anything inedible into their 
 mouths. A large part of the infantile education as to the physical na- 
 ture of the portable substances in reach comes from testing them in the 
 mouth ; but this natural tendency can be combated as can also the in- 
 fantile effort to assist dentition by biting on various substances. How- 
 ever, if mothers and nurses make a special elTort it is remarkable how 
 readilv most children even as early as the second year can be taught by 
 reproof. Younger children must be watched. The frequency with which 
 pins, buttons and safety-pins are removcil by endoscopists points to care- 
 lessness in leaving these things within the liaby's reach. Teething rings 
 and the toys of children should all be too large to get beyond the mouth 
 into the air or food passages, and all toys should be regularly inspected for 
 loose parts likely to become detached. Digital efforts at removal are 
 frequently res])onsil)le for dislodging and forcing downward foreign bod- 
 ies that could be readily removed from the ])harynx with forceps. The 
 index finger curling forward hook-like in an efiort to remove an object 
 from the laryngo-pharyn.x is very apt to force the object into the larynx. 
 Parents, nurses, dentists and physicians should bear this in mind. Nurses 
 and phvsicians understaufl fully about removing artificial dentures from 
 the mouth preparatory to anesthesia ; but they are not so often alert to
 
 208 FORKICN BODIES IN' AIR AND 1-OOD PASSAGKS. 
 
 the same potential dangers in case of unconsciousness from alcoholic 
 intoxication, delirium, syncope, shock, collapse and sleep, especially the 
 dozing or nap of the daytime. 
 
 Foreign bodies in the hysteric and the insane. We must always be 
 on our guard against the cases which come in with the most positive as- 
 surance by the patient that there is a foreign-body present. These cases 
 are of two classes. Those who have had a foreign body which has passed 
 on downward and left some traumatism, the sensations of which lead the 
 patient to believe that the foreign body is still present, and the hysteric 
 patient who believes she, or he has a foreign body. In regard to the 
 hysteric class, it is a great mistake to do a bronchoscopy with the ho])e 
 of cure by suggestion. Such "cures" are ephemeral. The foreign-body 
 illusion will recur with more and more persistence and amplification the 
 more often it is removed by suggestion. .\s is well known, two of the 
 most prominent characteristics of hysteria are the hunger for sympathy 
 and the desire to mystify and astonish the physician by unusual simula- 
 tions of disease. The border lines between pure hysteria and the hys- 
 teriform symptoms of paranoia on the one hand, and between the hys- 
 teriform and the suicidal symptoms of paranoia on the other hand, are 
 too abstruse for the author. These matters concern the psychiatrist. The 
 question that must be determined by the endoscopist is wdiether or not 
 to do an endoscopy and if so whether it shall be first a bronchoscopy or 
 an esophagoscopy in case indirect mirror examination prove negati\e. 
 In case of foreign body visible radiographically, or one that has pro- 
 duced a visible lesion such as abscess, the (|uestion is ([uicklv decided. 
 In all other cases there are four safe rules to follow : 
 
 1. Consider only objective symptoms. 
 
 2. Consider only testimony of persons other lh:in the patient as tc 
 history. 
 
 3. In all cases of doubt make a thorough endoscopic search. 
 
 4. If endoscopy is negative do not worry about the patient's later 
 assertion that she coughed up the foreign body that you failed to find. 
 It is parallel with the hysteric crijjples that throw away their crutches 
 after a faith cure. 
 
 Remarkable cases of nuilti|)le foreign bodies in the stomach of the 
 insane are not uncommon. A certain pro])ortion of these are almost 
 certain to be metallic, or of lead, glass or porcelain and dense to the ray. 
 Some such bodies may be removed wath the 10 mm. x ."i^ cm. esophago- 
 gastrosco[)e. .\s a rule, however, the objects that appeal to the insane 
 are of a kind that ajipears most appalling to them such as open pocket- 
 knives, shar]) glass and the like. These are best remo\ ed by the abdom- 
 inal surgeon by external operation. Should any object, of whatever kiiul.
 
 I-ORKIGX I'.OniKS IN AIR AND FOOD PASSAGES. 
 
 209 
 
 lodge in the esophagus, larynx or trachea, however, it should be removed 
 endoscopically, and it should not he pushed down into the stomach as 
 fatal trauma is \ery likely to result. In most instances it will he in the 
 esophagus that the endoscopist will be required for foreign body work in 
 the hysteric and the insane. The author has, however, had one case of 
 \()luntary aspiration of a foreign liody into the bronchi, following a 
 probablv accidental similar asiiiration. 
 
 Fie. 154. Racliograi)h by IJr. Lewis G. Cole, sliouiiii; two Uicl<s in ;i posterior 
 l)ranch of the right inferior lobe bronchus. Tacks removed by lironchoscopy 
 through the mouth. 
 
 A cose of voluntary aspiration of a foreign body into the bronchi, 
 removal by bronchoscopy. At the Eye and Ear Hospital, of Pittsburgh, 
 the author removed liy bronchoscopy, two tacks from a posterior branch 
 of the right inferior lobe bronchus of a woman aged forty-one years, re- 
 ferred by Dr. J.. G. Cole, of New York City, who made the excellent 
 radiograph (Fig. 1.54). The anesthetic was ether, given bv Dr. Homer
 
 210 FOREIGN BODIES IN AIR AND FOOD PASSAGES. 
 
 McCready. The bronchi were so full of pus that the patient nearly 
 drowned in her own secretions. After the bronchoscopic removal of the 
 pus the tacks (Fig. lo.")) were removed without difficulty, the first tack 
 requiring one and one-half minutes and the second one two minutes, as 
 timed by ]\Iiss Crock. At the operation the author had the kind assist- 
 ance of Drs. John W. Boyce, Homer McCready, Jesse Meyer (St. 
 Louis), Richard Lewisohn (New York). Four months after the re- 
 moval of the tacks, as reported in the foregoing, the patient came to Dr. 
 Cole's office at the suggestion of Dr. Geo. \V. Bogart, stating that she 
 had the same old symptoms, and she thought there must be more tacks 
 there. She further said that the tacks Dr. Jackson took out were cor- 
 roded, yet the last one just coughed up was bright and new. A radio- 
 graph showed one tack on each side of the thorax. Fig. l."i(>, not so near 
 the periphery as the previous tacks. The question then arose how could 
 the patient get the tacks into the bronchi voluntarily, as it was clear that 
 she was a hvsteric, if not demented. Dr. John \\". Bovce, in consultation 
 
 Fig. 155. Tacks removed by bronchoscopy from posterior branch of right 
 inferior lobe bronchus of a woman aged 41 years, referred by Dr. Lewis G. Cole. 
 
 on this point, said that by throwing a number of tacks into the pharynx 
 and taking a deep inspiration, she might get one or two down, but in so 
 doing she would swallow many more than she could aspirate, so that, if 
 not too late, a radiograph would show tacks in the alimentary canal in 
 progress of passing through. An excellent radiograph by Dr. Cole showed 
 four tacks in the abdomen (Fig. 1.57). The author removed the tacks 
 (Fig. l.iS) from the bronchi in the French Hos]iital of New York City 
 with the kind assistance of Drs. Robert C. Myles, J. H. Abraham, John 
 McCoy, T. Taylor and Geo. \V. Bogart, the head being held in the Boyce 
 position by Dr. D. T. Sable and the anesthetic ( chloroform) being skill- 
 fully administered by Dr. T. Drysdale Buchanan. There was a most in- 
 tense inflammation of all the bronchial mucosa and large quantities of pus 
 were removed. The tack in a posterior branch of the right middle lobe 
 bronchus was readily removed, requiring about two minutes, but the 
 second tack in the posterior branch of the left inferior lobe bronchus 
 was exceedingly difficult safely to remove. It was imbedded in bleeding
 
 FORKIGX BODII-.S IX AIR AND 1"()0I) I'ASS AGES. 
 
 211 
 
 granulation tissue, and the ])oint had perforated the opposite wall of the 
 next larger branch. After fifteen minutes' work the author succeeded in 
 disengaging the point and renKiving the tack. Two radiographs by Dr. 
 Cole immediateU- after the bronchoscopy demonstrated tliat n(; tacks re- 
 mained in the tliorax. 
 
 Kemarks. The first two tacks had. no doulil, been accidentally as- 
 pirated while ])Utting down oilcloth as stated by the ]iaticnt. The sym- 
 
 FiG. 156. Radiograpli by Dr. L. G. Colo, ul tacks \ > iluntarily aspirated by tlic 
 patient. 
 
 pathy, the interest, the seiisational features of the case, and the anes- 
 thetic evidently appealed to the neurotic temjK'rament of the patient, 
 and developed the hysteria which later was most troublesomely manifest 
 in ways unnecessary to enumerate. The case is unique in that it has 
 never before been demonstrated that a patient could vohnUarily aspirate 
 a foreign body info the bronchi, and it teaches a valuable lesson as to 
 how to detect the occurrence by radiography of the abdomen in cases 
 where an accident is denied. In all hysteric and insane patients a radio-
 
 212 FORKIGN liOnTI'S IN AIR AND FOOD PASSAGES. 
 
 graph slioiild be made alter removal of the foreign body as a matter of 
 record. 
 
 Procedure in a case of suspected foreign body. When a patient 
 comes complaining of a foreign body in the air or food passages the 
 (juestions that must he determined are : 
 
 1. Is there a foreign body present? 
 
 Fig. 157. Kacliuyraiih li\ Dr. L. O. CwL, shuuiii.;; Uicks in tlie intestines in 
 progress of passing through. Tacks were swallowed by the patient in attempt to 
 aspirate them. 
 
 2. Where is it located ? 
 
 3. Is a peroral endoscopic i)rocedure indicated? 
 
 4. Are there any contraindications to endoscopy? 
 
 o. Shall the first endoscopic procedure be laryngoscopic. broncho- 
 scopic or csophagoscopic ? 
 
 The questions listed above are so interlaced that they must be here 
 considered more or less collectively to avoid reiietition ; but to determine
 
 l"OUi:ir..\ [;oDIi:S IN AIR A\D FOOD PASSAGKS. 313 
 
 these (juesiious (|uiekly and, so far as possible, accurately requires orderly 
 investigative procedures as applied to the individual case. The various 
 steps as pursued in the autlior's clinic arc detailed below, in the order 
 given. ( )f course, if the foreign body is located in the earlier stcjis the 
 investigation may terminate at any stage. 
 
 1. History. 
 
 2. Indirect examination of the larynx; then the naso-pharynx, then 
 the tonsils or their neighborhood. 
 
 3. Radiography. 
 
 4. Physical examination locally in the neck and tli(jracically as well 
 as generally by an internist. 
 
 5. Endoscop)'. 
 
 History of the patient and deductions therefrom. Carefully taken 
 histories are valuable statistically and for determining the question of 
 the presence ami the localization of a foreign body. To be of value 
 statistically it is necessary that a blank should be filled out in order that 
 a record of certain details shall not be lacking in any of the histories. 
 
 il 
 
 Flc. 158. Tacks voluntarily aspirated. Removi.-il liy lironclmscoiiy ihroujili thf 
 mouth. Covcrcil with dricil lilooil ;iik1 secretions. 
 
 The aiUhor has used a blank of which l'"ig. \M is a reduced illuslratinn. 
 Ahnost all cases come in with a history of having "swallowed" the for- 
 eign body, and we must be on our guard not to accept this as meaning 
 that the foreign body is probably in the esophagus. As many of the 
 cases iuNoKc the (|uesti<)u of ;i foreign body not opaqtie to the ray, we 
 must depend up(jn other things for localization. First in importance, is 
 to lind out the sxniptoms at the time the foreign-body accident occurred, 
 anil ])arlicidarl\ ;is to whether or not there was cough or ilyspnca at the 
 time, followed with blood stained expectin-ation, because very often alter 
 a short period, the tolerance of the air passages manifests itself in a total 
 absence of symptoms. It is very rare. howe\er, that there is no cough- 
 ing at the time the foreign body entered; so that a total absence of 
 coughing, pro\ided some one is at hand whose observation is reliable, 
 strongly negatives the possibility of the foreign body having eiUerc<l the 
 trachea or larynx. This, of course, does not ajiply to ])atients under an- 
 esthesia, to the intoxicated, nor to anv case in which a calm, reliable oli
 
 214 
 
 FOREIGN BODIES IN AIR AND FOOD PASSAGES. 
 
 CASE 
 Name 
 
 Address 
 
 R^Si 
 
 Referred by 
 
 History taken by 
 
 Diagnosis 
 
 Hospital 
 
 Admitted 
 Discharged 
 
 Oq admission 
 
 General health 
 
 Age Date 
 
 Sex S..M,W.. 
 
 ..Owypptwu 
 
 -N^tJyitj.. 
 
 Private case or ward case. 
 
 Nature of foreign body 
 
 How long was the foreign body in air passage or esophagus^ 
 
 Immediate sj79p_tpms_prqduccd_by_fo_r_eign .body 
 
 Symptoms following entrance of the foreign body 
 
 Attempts made to remove it before direct examination 
 
 Pulmonary symjjtoms 
 
 Esophageal symptoms 
 
 Other symptoms 
 
 Result of X Ray examination 
 
 Kind of method employed for direct examination 
 
 J. .^.■. . . ^,*:^l- 
 
 Anesthesia b. General. 
 
 \ c. No Anesthesia. 
 Operative difficulties 
 Instrument em;>loye_d 
 
 Resulting instrumental lesion 
 
 Post-operative pulmonary and esophageal condition 
 
 Operation of particular interest 
 
 Duration of convalescence 
 
 Treatment 
 
 Result obtained 
 
 Autopsy 
 
 Bibhography 
 
 Surgeon-in-chief 
 
 Anesthetist 
 
 Msistants 
 
 Fig. 159. History sheet for foreign body cases. After the foreign body has 
 been removed, its location is entered on the top hne thus: "Case. Pin removed 
 bronchoscopically from dorsal branch of right inferior lobe bronchus."
 
 FOREIGN BODIICS IN AIR AND FOOD PASSAGES. 815 
 
 server was not present. The period of quiescence during which there 
 are no symptoms, may last from a few weeks to a few months before the 
 symptoms of chronic inflammatory conditions and irritations become 
 manifest. The reverse of this is not, however, so generally applicable; 
 because after some preliminary irritation in the region of the larynx ex- 
 citing cough, the patient may have swallowed the foreign body, and it 
 may have lodged in the esophagus. Then again, there may be severe 
 dys]jnea at the time either from the foreign body obstructing the larynx 
 or from pressure on the esophagus below the cricoid where the party- 
 wall is membranous. In one of the author's cases, a surgeon had done a 
 tracheotomy for the removal of a foreign body supposed to be in the 
 trachea because of great dyspnea. Xol finding the foreign body In the 
 trachea, the surgeon asked the author to pass a bronchoscope. On 
 bronchoscopy, through the mouth, the author found nothing in the trachea 
 or bronchi. Ksophagosco[))-, however, enabled us to find and remove the 
 foreign body (a coin above which meat and other food had become im- 
 pacted) in the upper third of the esophagus. The tracheotomy was per- 
 fectly justifiable and lifesaving because it was done for dyspnea, which 
 was relieved completely ; but it points a valuable lesson in regard to the 
 dyspnea produced by esophageally lodged foreign bodies. Intermittent 
 dyspnea or intermittent cyanosis after a history of choking on a foreign 
 body is practically diagnostic of a foreign body in the air passages. It 
 is most apt to occur in flat foreign bodies, which allow free passage of 
 air when their greatest ])l;ine corresponds to the long axis of the air 
 passages, but which are inure or less obstructive when they turn side- 
 wise. This may occur when the foreign body simply rotates in a semi- 
 fixed position. When the foreign body is free to move and is being 
 coughed up against the under surface of the glottis, there is, in some 
 cases, a very decided sudden stoppage of the glottic space by the bulk oF 
 the foreign body, probably plus more or less spasm which makes a very 
 characteristic sound that can be heard some distance from the ])atienl. 
 Tlie intiTinittint ilvspnea. in such a case, may occur not from a rocking 
 val\e-like action, biU sini]ily the intermittent occlusion of tlie subglottic 
 trachea. .\ remarkalile dilterence ijetween foreign bodies in the trachea 
 and Ijronchi as com])ared witli a similar condition in the esophagus is 
 that foreign bodies which are too small to cause dyspnea usually cause 
 the patient no inconvenience. I'",ven cough may be practically absent, so 
 that the i)atient is almost free from symptoms. In the esophagus, on the 
 contrary, the ]>;ilient usually feels the foreign body every time he at- 
 temijts to swallow, and there is usually a constant sensation of distress 
 and annoyance. Foreign bodies wliich have entered the air passages usual- 
 ly cause coughing and a sense of suli'ocation at the moment that the for-
 
 216 FORKICN P.OniK? I\ AIR AND FOOD PASSAGICS. 
 
 eign body enters the trachea : but thereafter, there is no sensation of 
 sufifocation unless the foreign body is very large, and there is usually no 
 other sensation. When an intruder enters the esophagus, on the other 
 hand, there is usually a sensation of something lodged in the throat and 
 the patient is impelled to make repeated swallowing efforts in the at- 
 tempt to dislodge it. Food may be regurgitated for a time and then 
 swallowing may seem normal, leading to the error of supposing the in- 
 truder has gone down. This may be due to the relaxation of the spasm 
 at first excited by the presence of the intruder, or it may be due to the 
 foreign body having turned to a less obstructive position. Ingals re- 
 ports a case in which small particles of corroded iron were coughed up 
 from a nail which had been in the trachea for a number of years. \Miile 
 such evidence is valuable when present it must not be taken negatively. 
 As pointed out by Iglauer (Bib. "223), the mere size of a foreign body 
 does not ])reclude its presence in the trachea. Determination of the 
 position of an esophageallv lodged foreign body by the sensation of the 
 patient is exceedingly misleading. The sensations that the patient feels 
 may be those of the spasm excited in a relatively remote position in the 
 esophagus, or the pains of other sensations may be reflected, but per- 
 haps the most important factor is that the sensations of the esophagus 
 are of a very ill-developed kind. Foreign bodies that ha\e lodged in 
 the larynx usually cause hoarseness in a very short time, and the cough 
 is apt to be of a croupy character. If. however, the foreign body is of 
 such a nature as to prop the cords apart there may be complete aphonia, 
 and this is almost diagnostic of a laryngeally lodged foreign body. Se- 
 vere dyspnea also usually points to glottic or subglottic lodgment. For- 
 eign bodies in the larynx are usually somewhat painful as compared to 
 those that lodge in the tracliea and bronchi, which are painless. There 
 is often a peculiar character to the cough when the foreign body pre- 
 vents glottic closure by working between the cords. .\s is well known, 
 the cords approximate and the cough comes with an exi)losive effort. 
 This mechanism is interfered with by the proi)i)ing apart of the cords 
 and hence the cough has rather the sound of an intubated patient, though 
 only to a slight degree. In children there is the usual tracheal cough ow- 
 ing to the collajjse of the tracheal walls during the expulsive eftorts. A 
 very hoarse, croupy cry usually means reactionary inflammation, and to 
 the trained ear there is a peculiar note produced in most cases by which 
 Dr. Ellen J. Patterson and the author have been able to diagnosticate the 
 presence of foreign bodies in a few instances. The note may be likened 
 to a croupy or}' with a metallic hiss added, though this description is in- 
 aderiuate to anyone who has not heard it. We do not know what pro- 
 duces the alteration of the ordinary croupy sound, unless it is the rush of
 
 FORKIC.N r.onil'.S IN AIU AND FOOD I'ASSAGF.S. 317 
 
 air past the foreign IkxIv. In one such case, referred to us by Dr. C. C. 
 Sandels, the sound amounted almost to a whistle, and was evidently due 
 to the rush of air past tlic thin edge of the hollow brass cap at the 
 "keeper-end" of a safety-pin. .\o radiograph had been taken and the 
 diagnosis of foreign body in the larynx was made by us solely on the 
 modification of the croupy cry. There was no history of foreign body 
 and the family and their physician were astonished to see the pin. 
 Every case with a foreign-body history should be followed up closely 
 until the foreign body is located either in the body, in the stools, or un- 
 til it is coughed up as the case may be. Under no circumstances should 
 it be forgotten or ignored as harmless in the absence of symptoms. 
 
 Indirect examination. When a patient comes in complaining of hav- 
 ing swallowed a pin and states he or she can feel it "here," pointing to a 
 location in the neck or chest, the patient should be placed at once in the 
 recunibcni position and ;i mirror examination should be made in this 
 irosition. The patieiil should, if possible, never be allowed to raise the 
 head until after the mirror and Roentgen-ray examinations. W hen there 
 is reason to suspect that a foreign body has entered the air passages, the 
 patient shoidd be kept recumbent and, preferably, face downward. Un- 
 der no circumstances should the patient be allowed to sit up or to lie on 
 either side. The reason for these precautions is to prevent gravitation. 
 If the patient is allowed to sit erect, the foreign body, especially if of 
 small size, will fall down into the deepest possible bronchus. If tlie pa- 
 tient is allowed to lie on the back, the foreign body will in\ade one of 
 the posterior branches which are exceedingly diHicult to reach. The ob- 
 jection to lying on the side is that this would fa\or the foreign body en- 
 tering the u|)per lobe bronchus, and especially \\(ju1(1 this be the case if 
 the foreign body should already be in one side and be dislodged and tak- 
 en over into the other side, lender such circumstances, tlic U])[)cr lobe 
 bronchus would be almost surely invaded if the patient w ere at the time 
 lying uj)on ihc previously nnin\adcd side. It is prol)al>le that lying upon 
 the face may cause the foreign body to enter the middle lobe bronchus, 
 but in the two cases of foreign bodies in the middle lobe bronchus in the 
 author's cx[)erience the extractions seemed easier than in cither cases in 
 which the jiosterior branches of the inferior lobe bronchus had been in- 
 vaded. I'urther evidence afforded by additional cases mav demonstrate 
 that middle lube bronchus cases are not easier. In this e\ent ddrs.il n- 
 cumbency would be better, but there can be no (|Ucstion that recumbency 
 is advisable because of the well proven tendency of foreign bodies to 
 work (low n\\;ird. I'.ecause of the briuiching angle of the middle lobe 
 bronchi and of the inferior lobe bmnchi, respecli\ely, in relation to the 
 long axis of the body, ventral recumbency does not make as steep a de-
 
 218 FOREIGN BODIES IN AIK AND FOOD PASSAGES. 
 
 clivity into the middle lobe bronchus and its branches as does dorsal re- 
 cumbency into the dorsal branches of the inferior lobe bronchus. The 
 fact of there being but one middle lobe bronchus also diminishes the 
 chances of invasion even though right sided invasion is more frequent 
 than left as will be referred to later. Next in importance is to quiet the 
 fears of the patient, and above all not to urge the patient to cough in the 
 vain hope of coughing the foreign body out. Not only are the chances 
 of success small, but the chances of a sharp foreign body, such as a pin, 
 burying its point are great. In the event of the point becoming buried, 
 there is very apt to be a very ratchet-like action by which the pin is 
 forced deeper and deeper, the point i)reventing upward movement. In 
 case of foreign bodies more or less cubical or globular in shape there is 
 risk that, in coughing, the foreign body may be jammed in the subglottic 
 space and thus asphyxia be threatened. The rule in regard to keeping 
 the patient recumbent does not apply to foreign bodies definitely located 
 in the esophagus, because gravity plays little or no part in the downward 
 mo\ement of anything in the esophagus under normal conditions. When 
 an esophagoscope is introduced conditions are altered. Having e.xam- 
 ined the larynx first, to make sure that there is no foreign body on the 
 brink ready to fall into the air passages below should the patient gag, the 
 tonsils and nasopharynx and neighboring regions should be carefully ex- 
 amined. In all of this inspection preliminary to endoscopy, abrasions of 
 possible foreign body origin should be looked for ; and the possibility of 
 certain kinds of foreign bodies, as needles, headless pins and the like, 
 having entered and disappeared into the tissues should be borne in mind. 
 In such cases discovery of the wound of entrance is of the utmost im- 
 ])ortance as facilitating remo\al liy pursuit or by enlargement of the 
 wound, which are justifiable in these higher regions in certain cases as 
 hereinafter explained. 
 
 I.ocalhation of esophageallv lodged foreign bodies ik'ith the bougie. 
 Nothing can be a more useless waste of time than the blind jiassage of 
 a bougie in an esophageal case, whether disease or foreign bodv is sus- 
 pected. It usually takes less time to pass an esophagoscope and remove 
 the foreign body or a specimen of neoplasm, or to make an accurate 
 diagnosis of disease than it does to pass the bougie ; after the passage 
 of which one usually has accomplished nothing. The last defense of the 
 blind bougie for diagnosis is based upon obsolete conditions. It is 
 claimed that thus can be determined the length of esophagoscopic tube 
 required. But there is no need of more than one tube for adults and 
 one for children. It is also stated that high disease of the esophagus 
 may be overridden or perforated by the mandrin of the esophagoscope 
 unless the location is [ireviously determined by blind bouginage. But
 
 FOREIGN BODIES IX AIR AND FOOD PASSAGES. 219 
 
 there is no need of a mandrin in introducing the esophagoscope. The 
 esophagoscope passed by sight is safer than the bougie. The latter is a 
 rehc of pre-esophagoscopic days. 
 
 RADIOGRAPHIC LOCALIZATION OF FOREIGN BODIES. 
 
 The author is quite unfamihar with the technicalities of Roent- 
 genology, and the suggestions herein given have been gleaned from ex- 
 perience in a large number of cases of foreign bodies (as well as of dis- 
 ease) the successful outcome of which has been due to marvelous work, 
 radiographic and interpretative, of such eminent Roentgenologists as 
 Cole, George C. Johnston. lioggs, Hickey, Grier, Foster, Gray, Bowen.. 
 Lang, Menges, Leonard, Cassabian, Pfahler. Eynian, Pancoast, Holding 
 and others. The suggestions here given are intended for surgeons who 
 cainiot avail themselves of the work of radiographic experts. After hav- 
 ing radiographically located a foreign body we must always remember 
 the possibility of the foreign body having changed its position between 
 the time the ray was taken and the bronchoscopy is done. The foreign 
 body may have shifted to another bronchus, or it may be even in a 
 bronchus of the opposite side. 
 
 Excellent progress has been made in the radiographic localization 
 of foreign bodies. This is especially true in regard to the technical im- 
 provements which have rendered possible the practically instantaneous 
 radiography, as it has cjuite recently been recognized (Tilley, Dundas 
 Grant and others) that an instantaneous radiograph will often show for- 
 eign bodies not visible with longer exposures. Moreover, there is less 
 chance for voluntary and involuntary movements of the patient, 
 which are transmitted to the foreign body, to blur the outline of the 
 intruder. Esi)ecially is this the case with very young children who can- 
 not be expected to hold their breath at command. Dr. George C. John- 
 ston has a number of times gotten a plate with beautiful definition free 
 from respiratory movement in an extremely dyspneic child with heaving 
 chest by snapping a number of momentary exposures at the respiratory 
 rest i)eriods after inspiration and before expiration. A deep inspiration 
 held during the exposure creates an artificial emphysema which causes 
 the foreign body to show, becai'se it lessens the density of the thorax : 
 though it must be borne in mind that the more horizontal position of the 
 ribs and the displacement of the viscera, including the foreign body must 
 be allowed for in the localization. The steady progress made by the 
 radiograi)iier in lateral radiography of the thorax has not only been 
 of great aid in the general localization from bony and visceral landmarks, 
 but also in conjunction with the caliper-guide suggested by Dr. Boyce 
 and ijcrfected by the .-luthor.
 
 220 
 
 FOREIGN BODIICS IX AIR AND FOOD PASSAGES. 
 
 The author puqjosely omits a talnilar record of the foreign bodies 
 that might be expected to show and those that ]irobal)l\- will not show. 
 His reason for the omission are : 
 
 1. The casting of a radiographic shadow depends not alone upon 
 the density of the foreign body but upon its thickness in the diameter 
 parallel to the rays. .\n example of this is seen in Fig. 160 and 101. 
 
 2. A body of little densit}' or diameter may happen to be so lo- 
 cated that Its shadow mav not lie overlaid bv normal shadows so that it 
 
 Fig. i6o. Radiograph showing bone in the esophagus. Note the swelling at the 
 esophageal walls and the clear outline of the air passages. (Author's case. See 
 Fig. .y.l. Plate made by Dr. George C. Johnston.) 
 
 may show. The author has seen a large number of examples of tin- 
 kind which are not here reproduced because the shadows while plainly 
 shown on the negatives lose too much in reproduction to show. 
 
 3. Lesions secondary to the foreign body may be revealed by the 
 radiograph and thus enable localization as in the case cited under "Pul-
 
 KOKKICN BODIKS I \ AIR AM) 1"00» I'ASS AGKS. 
 
 231 
 
 moiiary Abscess," and under "I.ocalizalion Films." In another case of 
 the aiulior a peanut kernel completely occluded the left upper lobe bron- 
 chus producing a shadow over the entire left upper lobe, though, of 
 course, the peanut itself did not show. The peanut kernel was bron- 
 choscopically removed from just within the orifice of the upper lobe 
 bronchus, liberating a large quantity of purulent secretion. 
 
 4. The foreign body may not be the same as that of which a his- 
 tory is given. The most common example of this is the pin or other 
 
 Fit;. 161, Railioiirapli of same patient. Tlic piece nf 1)(inc, tlnuisli present at 
 the level of the dart, does not show, partly because it overlies the spine but 
 mainly because in the lateral view the flat foreign body is seen on edge. An ex- 
 ample of the misleadmg negative radiograph, and an indication for lateral as well 
 3S antcro-posterior radiography. 
 
 dense object whicli has gotten into food and which, from the sensations 
 and from its presence in sou|)s. etc.. tiie patient refers to as a "bone."' 
 
 For the foregoing reasons the .luthor, e.xcept in cases of great ur- 
 gency, has a radiograph taken of every case. L'nless the radiographic 
 tube happens to be ])!accd exactly on a line that passes through the for- 
 eign body and that is exactly vertical to tlie plate, there will be a mis- 
 leading distortion as to the ])osition of the foreign body relatively to 
 anatomic shadows : because the rays passing the foreign body at a cer- 
 tain angle will continue to tra\el at that angle until they reach the plate.
 
 222 FOREIGN BODIES I.V AIR AND FOOD PASSAGES. 
 
 Therefore, the (hstortion will be in direct ratio to the distance of the 
 foreign body from the plate, and also in direct ratio to the distance of 
 the foreign body from any landmark, anatomic or artificial. While de- 
 ceptive, if misunderstood, or if the position of the tube is unknown, this 
 distortion has been turned to good account by enabling eminent Roent- 
 genologists (Johnston, Cole, Boggs, Grier, Pfahler. Boetjer and others) 
 to work out plans of localization by triangulation and otherwise, by means 
 of which the precise depth from any surface landmark desired can be 
 determined to a nicety. In one case, in which a foreign body was buried 
 in the inflammatory new-tissue produced during a ten years' sojourn, 
 the author's successful extraction of the foreign body was due to Dr. 
 L. G. Cole's accurate localization. In a similar case Dr. Alenges en- 
 abled the author to find a foreign body of seven years' sojourn. In quite 
 a number of instances Drs. Johnston. Grier, Boggs and others have 
 similarly rendered removals possible. The limitations of this method of 
 localizations are reached when we encounter foreign substances not 
 opaque to the ray. Borderline cases are those in which the body is not 
 sufficiently dense to show in more than one position of the patient, as in 
 a case of the author (reported on a future page) in which a glass collar 
 button could be shown only in a quartering lateral exposure, between the 
 heart and the spine. Fortunately, a very remarkable radiograph in this 
 position by Dr. George C. Johnston not only revealed the collar button, 
 but, by showing the trachea and bronchi, and still more wonderful the 
 inflammatory new tissue which blocked the bronchus above, enabled the 
 author endoscopically to cut away the intervening inflammatory obstruc- 
 tion to gain access to and remove the foreign body. A radiograph, first 
 in the anteroposterior plane and then in the lateral plane, has been very 
 valuable in assisting in a localization of a foreign body with reference 
 to a bronchoscope inserted to a certain definite location, which is fixed 
 in the memory of the bronchoscopist so that he can find the same loca- 
 tion at a subsequent bronchoscopy (Fig. ]li2). In doing this work, it 
 is essential that no anesthetic ether be used, because of the inflammabil- 
 ity of ether which might be ignited by a spark. If the foreign body is 
 very dense to the ray the fluorescent screen may be used with results that 
 are immediately available for work without withdrawal of the broncho- 
 scope. Of course this method by either radiography or fluoroscopy is 
 available only in case of foreign bodies dense to the ray. Manv foreign 
 bodies that are sufficiently opacjue to show in a radiograph are insuffi- 
 ciently dense to show in the fluoroscope. Localization by means of a 
 radiograph of the instrument in position at the suspected locality has 
 been used by the author in cases of pulmonary abscess (Fig. I'.Mi). The 
 same method may be used in esophageal cases in which the foreign body
 
 FOREIGN BODIKS IN AIR A Nil I'OOD PASSAGES. 
 
 223 
 
 Fig. 162. Antcro-posterior and lateral radiograph of recumbent patient with 
 bronchoscope in position. Useful for localization in case of small foreign bodies 
 SO far down and far out toward the periphery that they cannot be found. The po- 
 sition and direction of the intruder from the tube mouth, which is at a known and 
 subsequentlv lindalile location, locates the small branch bronchus to be searched at 
 a subsequent bronchoscopy. With, dense foreign bodies like the pin above shown, 
 the fluorescent screen may be used, yielding immediate information.
 
 22-1: FORl-ICX BODIHS IN AIR AND roOD PASSAGES. 
 
 is suspected to have wandered out of the himen into the tissues. Care 
 must be taken to avoid error from a foreign body being simply in a 
 fold in the lumen. A large esophagoscope should eliminate this jiossi- 
 hility. A sulisequent radiograph with pressure of the tube-mouth against 
 the pin will give positive evidence. A lateral as well as an antero-pos- 
 terior radiograph are necessary in any case. 
 
 The statements in the earlier work (Bib. 2G9) in regard to unre- 
 liabilit_v of fluoroscopy as compared to radiography for foreign bodies 
 have been borne out by further experience. A foreign body overlying 
 the spine or behind the heart shadow may be invisible by fluoroscopy and 
 yet show up strongly in such a location in the radiograph. In one in- 
 stance, a pin behind the heart shadow showed as black as if drawn with 
 a pen in a radiographic print, and yet was totally invisible to an ex- 
 perienced fluoroscopist with a proper tube. This was in an infant, and 
 therefore a very advantageous subject in which to see a foreign body on 
 the screen. With such results as these among the possibilities, it is use- 
 less to waste time with fluoroscopv for diagnosis as to the presence of a 
 foreign body, because with the instantaneous exposures and rapid de- 
 veloping of to-day. a report may be had in i)0 minutes or less from the 
 time the radiograph is taken. Fluoroscopy, however, may be of advan- 
 tage in foreign body cases in adults for another reason. An expert 
 fluoroscopist v.ith the recently developed apj^aratus can exclude aneurysm 
 and give a report on the functional acti\ity of the esophagus. With 
 foreign bodies not opaque to tlie ray at times information can be ob- 
 tained from fluoroscopic examination of the action of the diaphragm. 
 Under average conditions there may be a slightly greater activity of one 
 side as compared to the other, but any marked diminution of the ex- 
 cursion of the diaphragm on one side points to foreign body obstructing 
 the main bronchus. This is not diagnostic but is a strong indication for 
 bronchoscopy. Fluorescent bronchoscopy in which the bronchoscope and 
 forceps arc guided by the fluorescent shadow will be dealt with in a sub- 
 sequent chapter. 
 
 In case of a foreign body, which, from its nature, would show very 
 faintly, if at all, in the radiograph, the suggestion of Boyce to swallow 
 a bismuth capsule, is excellent. If the foreign body is sufticiently large 
 to be at all obstructive, the capsule will stop and remain at least for a 
 time at the site of the foreign body. (Fig. 16:5). This not only shows 
 that the foreign body is present, but it shows its position, and, further- 
 more, on dissolving of the capsule, the liismuth is beneficial to any trau- 
 matism or esophagitis that may exist in the neighborhood of the for- 
 eign body. In using the Ijismuth capsule, for the detection of a foreign 
 body not itself opaque to the ray, it is necessary to remember that the
 
 I'ORUIGX BODIES IN AIU AND FOOD PASSAGES. 
 
 225 
 
 progress downward of a bismuth capsule or any large bolus is not ex- 
 ceedingly rapid and may normally be seen in transit. Still more neces- 
 sary is it to remember that in many cases, with a perfectly normal esoph- 
 agus not containing any foreign body, the capsule may hesitate for a 
 moment at the cricopharyngeus and also at the point where the left 
 bronchus crosses the esophagus, and again at the hiatus. The author has 
 noted in quite a number of cases with an apparently perfectly normal 
 
 Fig. 16,3. kadio.uraph sliowiiig a mctlii>d of locating a foreign body in the eso- 
 phagus. The bismutli capsule was slopped in the esophagus by a foreign body that, 
 itself, does not show. 
 
 esophagus that the ridge caused by the crossing of the left bronchus was 
 undtilv prominent, and this, in one case, was connected directly with a 
 lodgment of the bismuth capsule for a few seconds in an esophagus which 
 did not contain ri foreign body. In view of this, it would seem to be wise 
 in using the capsule for the diagnosis of foreign bodies not opaque to 
 the rav to wait two or three minutes after swallowing the capsule before
 
 226 Foreign eddies ix air and food passages. 
 
 taking a radiograph ; but, of course, the wait must not be sufficiently long 
 to permit of the capsule dissolving. In case of small non-obstructive 
 foreign bodies the metliod would not be efifective, and in any case is value- 
 less negatively. \\'hen positive it may be so from an obstruction other 
 than a foreign body. 
 
 Interpretation of a radiograph is best done by the radiographer ; a 
 few hints to the endoscopist, however, may not be amiss. First in im- 
 portance is to determine whether the foreign body is in the respiratory 
 or in the alimentary tracts, and next in importance is to determine in 
 what part of the respective passages the foreign body is lodged. This 
 is extremely easy in some cases, extremely difficult in others. As a 
 rule, it may be stated that foreign bodies more or less flat, whose plane 
 corresponds to the lateral plane of the body, are in the esophagus and 
 not in the air passages. This applies with a special force to the upper 
 half of the esophagus because the esophagus is collapsed antero- 
 posteriorly ; that is, the anterior wall lies against the posterior wall. The 
 direction of least resistance being laterally, flat foreign bodies project 
 their longest diameter laterally. In the trachea, also, there is a slightly 
 greater diameter laterally at the bifurcation and for some distance above 
 it. Above the sternal notch, however, foreign bodies entering through 
 the glottis are almost always found to have taken the anteroposterior 
 position because of the greater axis sagittally of the laryngeal and sub- 
 glottic lumina ; and this position is most likely to be maintained 
 below, because the posterior wall of the trachea is membranous and 
 yielding. These points are well illustrated in the radiographs Figs. 1(34 
 and Kio, and are especially plainly marked in lateral radiographs of for- 
 eign bodies in the esophagus as illustrated in various parts of this book. 
 It is customary in the interpretation of a radiograph, when one lung 
 shows dark and the other light, to consider that the dark side contains 
 the foreign body which has occluded the main bronchus with perhaps 
 compensator}- emphysema on the opposite side. Iglauer (Bib. 222) re- 
 ports a very interesting case where this reading was erroneous because 
 the foreign body had, by a vahe-like action, imprisoned more air in the 
 obstructed side, so that there was a verv marked emphysema shown by 
 the radiograph on the obstructed side. 
 
 Calcified glands are exceedingly common and may, in some instances, 
 lead to error. As pointed out by Dr. George C. Johnston, in connection 
 with one of the author's cases, that of a molar tooth in the bronchus of 
 a boy, calcified glands are always rounded in form, so that in case of any 
 body not of rounded form, there is little likelihood of error ; but it must 
 be remembered that the foreign body must be considered from every 
 point of view, as irregular-shaped bodies may throw a rounded shadow in
 
 FOREIGN BODIES IN AlK AND l-(X)I) PASSAGES. 
 
 327 
 
 certain positions. Furthermore, calcilicd f,'lands arc rarely single, so 
 that any suspicious shadow is apt to he duplicated, if due to a calcified 
 gland. Von Eicken, in a very interesting paper (Bib. oliS), reports 
 a case in which a shadow was thought by the Roentgenologist to be due 
 to a calcified gland, and so it proved to be. There was, nevertheless, in 
 
 Fic. 164. Radiograph of a coin (half-dollar) in the esophapus of a child of 
 14 years. This illustrates the method of localization of foreign bodies in the esoph- 
 agus. It is utterly impossible for a Hat body of this size to be trachcally lodged 
 thus in the lateral plane of the trachea. 
 
 the case a forei.^n liody (hone) which did not siiow in the radiograph, 
 but which was discovered and removed by bronchoscopy. 
 
 Posith'c films of the tracheo-bronch'ml tree as an aid to localization. 
 A large foreign bod_\- in a large bronchus needs accurate localization, not 
 but that it could be limnd bronchoscopically in every case; but accur- 
 ate localization enables tiie bronchoscopist to go at once to the known lo- 
 cation and thus greatly shorten the period of endoscopic search which
 
 22S 
 
 FOREIGN BODIES IN AIR AND FOOD PASSAGES.
 
 FOREIGN BODIi:S IN LARYNX AND TRACHKA. 
 
 239 
 
 may be a vital point. 'J'hcre is another class of cases, howe\er, in which 
 the intnider may never be found if there has been no accurate localiza- 
 tion. Small foreign bodies, or those small in one diameter, following the 
 general rule of foreign bodies in the air passages, keep on going down- 
 ward until they get into the smallest possible bronchus. Thus needles 
 and small headed pins get very far down and \ery far out toward the 
 perijihery of the lung and into a very small branch bronchus of which 
 
 Fig. i66. Illustration of a positive film used for overlaying to assist in lo- 
 calization of foreien bodies or lesions in the thorax. The lower white line ( U, 
 D) corresponds to the diaphragm, the nrddlc line (1' 1') In ihe dome of the 
 pleura. These Hnes assist in placing the overlay. The upper line (V C), cor- 
 responding to the vocal cords, is occasionally useful. Twelve photographic en- 
 largements arc on hand so that a film of the size (rather than the age) is avail- 
 able for any sized patient. The few minute branches that go below the line, D. 
 are those posterior to the apex of tl.e dome. 
 
 there are many. To search all nf ilicsc with a probe or niiiuiie tube con- 
 sumes a large amount of lime. The atithor has devised ior help in these 
 cases a positive transparent film of the tracheo-bronchial tree ( b'ig. HWi). 
 The film being a "positive" the tree is transparent. The him is laid over 
 the negative of the ])atienl sliowiiig the foreign I'odv. when the foreign 
 body will show through the transparent tracheo-bronchial tree of the 
 ovcrlving positive film. In pl.acing the film, bony landmarks are not re-
 
 230 
 
 FOREIGN BODIES IN AIR AND FOOD PASSAGES. 
 
 liable because of the wide variation due to the phylogenetic recency of 
 the upright posture. X'isceral landmarks are necessary. The two im- 
 portant visceral landmarks are the dome of the pleura and the dome of 
 the diaphragm. It is needless to say the tracheo-bronchial tree necessarily 
 lies in the body of the lung between these two landmarks, and lines cor- 
 responding to these are placed on the film. Twelve photographic enlarge- 
 ments and reductions are on hand so that a film of the size (rather than 
 age) is available for any sized patient, the size being chosen by matching 
 the size between the dome of the pleura and that of the diaphragm as 
 shown on the radiograph of the patient. All this work is done, of course, 
 in a darkened room, with a stronglv illuminated shadow-box; and in the 
 
 Fig. 167. Ilhi.'itratii,!.' on tlie left, aliscess ( rctouclicd). On the right the abscess 
 is localized in the right inferior lolje bronchus by the method of overlaying. The 
 localization coincided with the endoscopic findinus'when the abscess was evacuated 
 bronchoscopically. 
 
 event of the foreign body showing very faintly on the radiograph of the 
 patient, it is strengthened by an ink-mark on tlie uncoated side of the 
 negative, which can be readily erased afterwards if desired. 
 
 Corroboration of the usefulness of these films has been forthcoming 
 from a number of sources. (See article by R. C. Lynch in New Urleans 
 Med. and Surg. Journal, Dec, 1913). 
 
 To prevent error in the use of these films, as with any method of 
 interpretation of a radiograph, it is necessary to be on guard against 
 false localization due to displacement of the lung by atelectasis, and es- 
 pecially by the compensatory emphysema on the other side. Another 
 source of error, of course, is that the positives of the tracheo-bronchial 
 tree are made from the tracheo-bronchial tree of a cadaver, whereas 
 bronchoscopic study of the tree shows that it is not quite in the same
 
 FOREIGN BODIES IN AIR AND FOOD PASSAGES. 
 
 231 
 
 position in the living. The injection prejiarations of I'.runings come 
 nearer those of the li\ing tree than any other that the author has been 
 able to find, and therefore he has used them in making the positive films. 
 Caliper-guide method of localization. This method, suggested by 
 Dr. John \\". Boyce and perfected by the author is intended primarily for 
 bringing the tube mouth in close relation with a small foreign body that 
 cannot be found because it is in a minute bronchus of which there are 
 too many for each to be searched. In conjunction with the lateral radio- 
 graph the caliper-guide will bring the point of the bronchoscope, after- 
 ward at bronchoscopy, in close relation with the foreign body, thereby 
 greatly diminishing the number of small bronchial tubes to be searched ; 
 this method being used, of course, onlv in case of small foreign bodies 
 
 Fig. i68. lUustratitiK a positive radinRraphic film of tlic traclico-hroiicliial tree 
 u.sed for overlayincr to assist in localization of a foreign 1)0(ly. The left hand illns- 
 tration shows the lilm laid over a negative of a patient in whose left main hronclms 
 was a pin. Localization verified by bronchoscopy. The shadow of the pin is 
 strengthened with ink. 
 
 which have fallen into a very small bronchus far down or far out near 
 the periphery of the lungs. The lateral placement of the point of the 
 bronchoscope depends ujion a m;irk placed on the skin by the radio- 
 grapher who determines the |iiiiin liy an anterior-posterior radiograph 
 (Fig. Ifiti). 
 
 Value of luuiativc radiography. The negative rejjort from liie radio- 
 grapher remains to-day as it always has been, unreliable, I)ecause many 
 bodies are not opaf|ue to the ray, and. moreover, the foreign body may 
 not be the same as that of which we get ;i history. In addition to this, 
 even metallic bodies at times do not show, b'or instance, in one of tlie 
 author's cases, that of an enormous woman of Tv.\ years, expert radio-
 
 233 FOREIGN BODIES IN AIR AND FOOD PASSAGES. 
 
 graphers, for a period of two years, made quite a number of exposures 
 that failed to demonstrate a tack which they finally demonstrated to be 
 present (Fig. ]70) and which the author removed bronchoscopically. 
 Such occurrences will doubtless be less and less frequent because of the 
 steady advance in the technical perfection of radiography. A number of 
 
 Fig. 169. Illustrating llie position of the caliper-giiiile in getting the adjust- 
 ments by which the point of the bronchoscope can be brought, later at bronchos- 
 copy, in close proximity to a foreign body. For use in case of small foreign 
 bodies in minute bronchi. Suggested l)y Dr. John \V. Boyce and perfected by the 
 author. Inadvertently, in making the illustration, a radiograph of an esophageal- 
 ly lodged foreign body (safety-pin) was used, but the principle is illustrated just 
 as well. 
 
 recent cases have made it quite clear tiiat it is necessary to do a bronchos- 
 copy if there is any reason to suspect from the history that there is a 
 foreign body located somewhere in the air-passages or in the esophagus, 
 notwithstanding a negative ray finding and a total absence of symptoms, 
 for it is remarkable how tolerant the trachea, bronchi and the esophagus 
 become to the presence of foreign bodies after the initial symptoms im-
 
 I"I)RKIGN HODIi:s IN AIK AND Kndl) PASSAGES. 
 
 233 
 
 mediately following the accident liavc subsided. A negali\-e .\-ray may 
 be very misleading, because, as shown by b'rank C. Todd ( llib. ."ill) a 
 radiograph may not include the region in which a foreign body is located. 
 Xotwilhstanding the fact that there was no clear history of a foreign 
 body having been seen in the child's possession, and despite the negative 
 radiograph, Dr. Todd bronchoscoped the child without a general anes- 
 thetic and skilfnlly remo\-ed the tack. j. W. .Murphy (Rib. 3!IT) reports 
 
 P'li;. I/O. kiuiioyraph .showing tack in lironclnis 
 
 a woman 
 
 '• 5,i years. This 
 
 tack failed to show in radiographs taken by expert radiographers at intervals for 
 a period of two years before getting the tack to show. Tack rciTiovo<l lironcho- 
 tcopically by the author. 
 
 experiments demonstrating the fact that the ei impnsitiim nf wliich most 
 buttons are mafle did nf)t show in the radiograph, and ili.ii with phy- 
 sical signs, sensations of the ])atient, and the radiograph all negative, the 
 foreign body, nevertheless, was present. In one of the author's cases 
 (illustrated on a subsequent page) the metal |iart of a shoe button 
 showed but the composition i)art clid not. As before mentioned it is 
 needless here to consider in detail the different kinds of foreign body as
 
 234 FOREIGN BODIES IX AIR AND FOOD PASSAGES. 
 
 to their density to tlie ray, because a radiograpli sliould be taken in 
 every case; and if negative an endoscopy should be done anyway if there 
 is reason to suspect a foreign body. Those who are interested in the 
 relative densities are referred to the interesting article of von Eicken 
 (Bib. 5G3). 
 
 Pliysical c.vamhiatioii of the chest. Should the foreign body be 
 located by radiograph, physical examination of the chest is, nevertheless, 
 necessary for two reasons. 1. The data to be obtained will be, when suf- 
 ficient has been accumulated, invaluable for other cases in which the 
 foreign body is not dense to the ray. 2. The condition of all the viscera 
 in the thorax and elsewhere should be known before endoscopy. The 
 notes on the physical signs of foreign body, by Dr. J. W. Boyce (Bib. 2U!', 
 p. !Hi), have stood the test of further experience. In case of complete 
 occlusion of one bronchus, there may be a verv marked diminution of the 
 respiratory excursion of the thorax on the attected side, as observed by 
 Dr. John R. Simpson in one of the author's cases. The same signs have 
 since been obser\-ed in a number of other cases. The author is \itterly in- 
 competent to make a physical examination of the chest by auscultation and 
 percussion. But comparing the findings of verv competent physical diag- 
 nosticians with the author's endoscopic findings, he is strongly impressed 
 with the fact that foreign-body cases are nearly always associated with a 
 large amount of secretion because of the difticulty in expectoration, and 
 especially is this the case in children. In some instances, physical signs of 
 solidification have completely cleared up after the author has bronchoscop- 
 ically removed a large quantity of secretion. This accumulation of secre- 
 tion is especially liable to occur in the lower lobe, and (H. T. Price) it 
 may be limited to one lower lobe even when the foreign body is in the 
 trachea. In some instances the intruder was known to have been in the 
 trachea for a number of weeks. This prolonged sojourn negatives the 
 hypothesis that the foreign body might have been in a lobe of one lung at a 
 previous time, resulting in the excessive secretion. It seems certain that 
 the secretion had tlrained downward and accumulated because of the dit+i- 
 cult expectoration, an<l that some peculiarity either in form or position of 
 the right or the left bronchus, or some ditterence in ciliary action has fa- 
 vored the greater accumulation on one side as compared with the other. A 
 number of interesting facts bearing on the physical signs produced by the 
 lesions following [prolonged sojourn of a foreign body in the lung will be 
 given along with the case reports in the section devoted to this class of 
 cases. The similarity to the physical signs of pulmonarj- tuberculosis is 
 remarkable. Bronchiectasis may be jiresent with its jihysical signs.* 
 
 *\ unique case in which Dr. George I^. Richards di.iErnosticated a foreian body 
 on physical and laboratory findings, in the absence of a history, is recorded in the 
 iransactions of the American Laryngological, Rhinolog-ical and Otologleal
 
 I'OKi:u'.N I'.iiDIKS IN AIK AXD FDiiD I'ASSACKS. 235 
 
 ERRORS TO AVOID IN SCSPnCTKI) I'ORElGN-liUUY CASKS. 
 
 1. Do not reach for the foreign hody with the finger, lest the foreign 
 body be thereby pushed into the larynx, or the larynx be thus traumatized. 
 
 2. Do not make any attempt at removal with the patient in any posi- 
 tion other than recumbent witli the head and shoulders lower than the 
 body (Fig. T:!a). 
 
 ;>. Do not h(jld uji the patient by the heels, lest the foreign body be 
 dislodged and asphyxiate the patient by becoming jammed in the glottis. 
 
 •1. Do not fail to have a radiograph made, if possible, whether the 
 foreign body in (|uestion is of a kind dense to the ray or not. 
 
 '). Do not fail endoscojjically to search for a foreign bmly in all 
 cases of doubt. 
 
 I'l. Do not pass an esophageal bougie, probang or other instrument 
 l)lindly. 
 
 7. Do not tell the patient he has no foreign bod\- until after radio- 
 graphy, i)hysical examination, indirect examination, and endoscopy all 
 have proven negative.
 
 CHAPTER XIII. 
 
 Foreign Bodies in the Larynx and 
 Tracheobronchial Tree. 
 
 Etiology. In the air passages, which are not intended for sohds. 
 foreign bodies that get in through natural passages can only do so by 
 passing the normal safeguards which are mainly reflexes. Hence any- 
 thing which interferes with these reflexes is the chief etiologic factor. 
 Sleep, anesthesia, intoxication, syncope, delirium, mechanical mterference 
 of masses of disease as in malignancy, tuberculosis, etc. The reflexes 
 may interfere with each other ; as, for instance, the sudden inhalation 
 which precedes or follows coughing, laughing, sobbing, and unusual ex- 
 ertion. The protective reflexes act chiefly in two groups. The laryngeal 
 closing reflex and the bechic reflex. Laryngeal closure for normal swal- 
 lowing is chiefly in the tilting and closure of the upper laryngeal orifice. 
 The ventricular bands help but slightly and the epiglottis and the vocal 
 cords not at all. Foreign bodies going in with the inspiratory blast, must 
 run the gauntlet of the following guards : 
 
 GAUNTLET TO BE RUN BY FOREIGN BODIES ENTERING THE LOWER AIR 
 
 PASS.\GES. 
 
 1. Epiglottis. 
 
 2. upper laryngeal orifice. 
 
 3. Ventricular bands. 
 
 4. Vocal cords. 
 
 5. Bechic blast. 
 
 The epiglottis makes somewhat of a fender, efficient in projiortion as 
 it hangs backward toward the posterior pharyngeal wall. The upper 
 lary-ngeal orifice, composed of a pair of movable ridges of tissue has al- 
 most a sphincteric action, besides its tilting movement. The ventricular 
 bands can appro.ximate under powerful stimuli. The vocal bands 
 act similarly. The one defect in the etificiency of both sets of
 
 FOREIGX i;oi)Ii;s IN LAKVXX AND TRACHEA. 237 
 
 bands in barrinj;; out intruders is the tendency to take an inspiration pre- 
 paratory to the cough excited by the contact of a foreign body. This 
 inspiration is not invariably taken, however. A sHght explosive cough 
 can be taken without inspiration, especially if it start near the end of an 
 inspiration, but following this or any other coughing effort is a deep in- 
 spiration which is i)robably the most etticient factor in the entrance of 
 foreign bodies into the lower air passages. 
 
 Gottstein collected statistics which showed that (i(i per cent of the 
 cases of foreign bodies in the air passages occurred in children. This 
 may be in part due to a less degree of automatic protection to the en- 
 trance of foreign bodies in the air passages; but doubtless is, to a greater 
 extent, due to the fact that children are prone to I'lay, run, laugh and 
 attempt to speak with various foreign bodies in the mouth. It does not 
 seem probable that children put foreign bodies in their mouths more fre- 
 quently than adults when it is considered how many women are in the 
 habit of putting pins in their mouths especially when dressing, and how 
 many workmen jilace small foreign bodies, such as tacks and nails and 
 the like in the mouth. C)f course in infants there is a well known ten- 
 dency to put everything into the mouth, as this seems to be one of the 
 means by which the infant mind acquires knowledge of material things. 
 Soluble material, such as candy, or foods which very quickly disinte- 
 grate, such as bread, toast, and the like, need cause no uneasiness, as they 
 are very soon coughed up and expectorated. Meat, if composed purely 
 of muscular fiber or fat, is practically always expectorated. If, however, 
 it is firmlv attaciied to periostium or bone or cartilage, it may constitute 
 a foreign body for which bronchoscopy should be done. It is quite re- 
 markable that all strictly food substances are rather rare in the bronchi, 
 while the portions of food which should be and usually are rejected, are 
 not at all uncommon, such as the seeds of fruits, the shell of nuts, bone 
 and the like. ()f course it is not nicmt to refer here to the various food 
 substances such as dried maize, beans, ])eas and the like, which are put 
 into the mouth by children in play and not strictly for food. It is well 
 known that any light particles of dust usuallv are largely removed by 
 the cilia, while heavier particles of dust become encysted as in anthracosis. 
 Just where the border line exists lietween the foreign body of such small 
 size that it ma_\- become encysted, and the larger bodies which will form 
 an abscess, has never been determined, and it is very difticult to determine 
 because the smaller bodies which form an abscess usually become dis- 
 integrated, or are lost in pus and are never discovered. It seems quite 
 certain that a large proportion of the non-tuberculous pulmonary ab- 
 scesses are due to this cause. In the author's collection, pins are the most 
 frequent of foreign bodies in the bronchi. Next comes various forms of
 
 238 Foreign eudies in larynx and trachea. 
 
 hardware, and then various vegetable substances, bones and coins. Pea- 
 nut kernels are among the most fatal of foreign bodies, and this does not 
 seem to be due to comminution and multiple abscesses, so much as to the 
 peculiar irritating effect of the peanut kernel upon the tracheo-bronchial 
 mucosa. A metallic body will be tolerated for a long time with little re- 
 action, whereas a peanut kernel will set up violent local reaction in a few 
 days as shown by the author's cases to be cited later.* Dr. E. \V. Car- 
 penter (Bib. 73) reports the case of an infant of sixteen months that 
 was asphyxiated by the pus liberated from an abscessed lung following 
 the aspiration of a peanut. J. A. Stucky (Bib. .Til) and many others re- 
 port fatal cases. Metallic bodies if of such shape as completely to occlude 
 a bronchus, usually cause rapidly developing fatal abscess by the stagna- 
 tion of secretions which cannot be coughed out. On the other hand for- 
 eign bodies that do not occlude the lumen may produce little reaction for 
 a long time, provided the lumen is not occluded by the reactionary swell- 
 ing of the mucosa. Sooner or later this occlusion occurs, however, and 
 the patient usually succumbs. Considering the millions of people who 
 are carrying about with them loose teeth or loose artificial dental attach- 
 ments it is a very remarkable thing that relatively so few foreign bodies 
 to be classed as dental find their way into the air passages. Large arti- 
 ficial dentures are bv no means uncommon in the esophagus and of 
 course by reason of their size they could not well get into the air pas- 
 sages. In the author's opinion it is a great tribute to the skill of den- 
 tists that so few foreign bodies are to be classed as dental. Teeth may 
 be knocked loose in a fall and be aspirated as in one of the author's cases. 
 In another case he treated laryngeal stenosis that followed an abscess 
 caused by impaction of a tooth in the subglottic region. The rootless 
 deciduous tooth had shot out of the dental forceps in the hands of a 
 skilful dentist. Dried vegetable substances such as beans, peas and maize 
 soon occlude the lumen and are rapidly fatal. Those interested in the 
 further pursuit of this interesting phase of the foreign body question are 
 referred to the excellent article of D. Bryson Delavan (Bib. 107) which 
 also gives a number of references. An excellent article on the experi- 
 mental pathology of foreign bodies in the lungs was written bv George 1'. 
 Wood. (I5ib. .^85.) 
 
 iriiy do forciijn bodies lodge at certain localities in the air passages? 
 Lodgment at some of the most fre(|uent sites is accounted for by seem- 
 ingly adequate reasons. The factors may be classed in two main divis- 
 ions : 
 
 1. (a) The size and shape of the foreign body: whether long, 
 broad, pointed, angular, disk-like, etc. (b ) Its surface, whether rough 
 
 *So uniformly Is this olaserved that the term "peanut bronchitis" has come 
 into rommon use in the author's cUnic.
 
 FOREIGN BODIES IX LAKV.W AND TKACIIF.A. 239 
 
 or smooth. (2) Its physical properties, resiliency, plasticity absorptiv- 
 ity, etc. 
 
 2. The anatomic peculiarities of the various localities, (a) Angles, 
 arcs, (b) Fixed and motile narrowings. 
 
 The size, shape and surface of the foreign body has less to do with 
 the particular site at which it is most likely to lodge than have the anatom- 
 ical regional peculiarities. A pointed body may catch at any location 
 if the point be downward as it often is in the esophagus. In the air 
 passages, however, pins are almost invariably head downward, and by 
 a ratchet-like action, the point preventing return, work toward the low- 
 est point. In the air passages the narrowness, quiescent and spasmodic 
 of the larynx halts many foreign bodies which may be retained because 
 of peculiarities of their shape, or by a projection; or by entering a 
 ventricle. As in one of the author's cases, that of a safety-pin, one part 
 may drop through the glottis while another part not passing through, the 
 intruder is i)revented from going either way. Having passed the cords 
 a foreign body may be wedged in the subglottic space, either on its way 
 down or when it is shot back upward by the bechic blast. Below the 
 subglottic siKice the next point of fre(iuent lodgement is the bifurcation. 
 Lodgement here is due rather to the shape of cross-section, elongated 
 laterally witii two openings laterally below, causing the intruder to be 
 caught crosswise. More often it is the etfort of the intruder to enter 
 either the right or the left bronchus, both of which are smaller than the 
 trachea. The bronchi do not diminish between branches. That is, the 
 diminution is at the points of subdivision ( monopodic branching, not 
 true bifurcations), and between these the bronchus is cylindroid, not 
 tapered. Therefore a foreign body usually halts with its largest diam- 
 eter at or immefliately below a point where a lateral branch is given off. 
 
 Greater frequency of riglit-broncliial invasion. The right bronchus 
 is invaded by foreign bodies more frequently than the left. Statistics 
 collected by Gottstein show that 7-"). 4 ])er cent of foreign bodies entering 
 the bronchi w'ere in the right bronchus. \'on Eicken found 70.2 per cent- 
 Prcol>raschensky, Oil per cent. Morrell Mackenzie, 02. .5. The reasons 
 for this are anatomical and physiological. 
 
 1. The greater diameter of the right bronchus. 
 
 2. Less angle of deviation of the right bronchus. 
 
 3. Situatiiin of the carina to the left of the long axis of the trachea. 
 
 4. The action of the trachealis muscle. 
 
 5. The greater volume of air going into the riglit broiicluis on in- 
 spiration. 
 
 The first three of these factors are shown in the schema Fig. 1T1, 
 The riglit bronchus is in size and direction the continuation of the
 
 240 
 
 I'OREIGN BODIES IN AIR AND FOOD PASSAGES. 
 
 trachea ; the left bronchus in many cases simulating a lateral branch of 
 the trachea rather than a bifurcational half. The situation of the carina 
 to the left of the long axis of the trachea is important. Heller and 
 \'. Schrotter found the carina to the left in 57 per cent, in the middle 
 line in -13 per cent and to the right in 1 per cent. Sir Felix Semon and 
 Morrell Mackenzie's joint results were: left, .59 per cent, middle line. 
 3.5 per cent, riglit, il per cent. These statistics are all based on the cad- 
 averic anatom)-. The author feels certain that the living anatomy shows 
 a much more marked preponderance of left-sided situation of the carina. 
 
 Fig. I/I. Schema showing three anatomical reasons for the greater frequency 
 of right-sided lodgement of foreign bodies in the bronchi. The right bronchus 
 (Rt. B.) is almost as wide (2.3 mm.) as the trachea (24 mm.) and it deviates much 
 less than the left from the long axis of the trachea. The carina, C, is to the left 
 of this axis, (.\fter Sir St. Clair Thomson.) 
 
 He regrets that he did not keep a record of this point in all of his bron- 
 choscopic cases. But in 40 cases where he kept a record the carina 
 seemed more or less to the left in all but one and in that case the carina 
 seemed central. These cases were, without known pathology that could 
 alter the position of the carina. The observation is submitted with ac- 
 knowledgment of the possibility of error, because of the alteration of 
 position of all the thoracic viscera due to position of the patient, the 
 bronchoscopic tube and the pulsatorv and resjiiratory movements. Fur- 
 thermore, the observations were incidental antl no time was taken to in-
 
 FOREIGN BODIKS IN AIR AND FOOD PASSAGES. 241 
 
 sure accurac}'. From j^eneral observation and the instinctive habits of 
 work, the aiitlior has come always to move the head to the right to get 
 into the left bronchus while the head is not moved to the left simply to 
 cause the bronchoscope to enter the right bronchus. It always goes 
 there naturally with the head in the middle line, though, of course, the 
 author's custom of turning the lip of the bronchoscope to the right for 
 entering the right bronchus assists. The action of the musculature at 
 the carina in drawing the carina to the left and thus reducing the size 
 of the left bronchial orifice is thought by Snow to be one of the chief 
 factors in the preponderance of foreign bodies in the right bronchus. 
 The fifth factor mentioned above does not seem to have received the 
 attention it deserves. In one of the author's cases, that of an extremely 
 dyspneic child, there was demonstrated by physical examination by 
 Dr. H. T. Price very little air going into the right side and none at all 
 into the left. The foreign body was in the subglottic space. This case 
 seems to pro\e what theoreticallv would seem probable from the greater 
 size of the right lung, that there is a greater volume of air rushing 
 through the right bronchus at each inspiration. 
 
 Why is the middle lobe bronchus rclatiiely so rarely invaded by 
 foreign bodies? The middle lobe bronchus is rarely invaded. The 
 author has seen but two such instances, in over two hundred cases of 
 foreign body in the bronchi. The relative rarity of invasion possibly is 
 due to the fact that the middle lobe bronchus is given off anteriorly^ 
 consequently gravity tends to lead the foreign body into posterior 
 branches because the patient docs not lie on his face but on his back. 
 This theory of the author has never been positively proven because for- 
 eign bodies are rarely radiographed soon enough after the accident, i. e., 
 before the patient has lain down. Excluding the effect of gravity, the 
 angle of the giving off the middle lobe bronchus does not seem less 
 favorable for the invasion by a foreign body than do some of the dorsal 
 branches of the inferior lobe bronchus which are so fre(|uently invaded. 
 True, in looking down the lumen of the rigiit stem bronchus the orifice 
 of tlie middle lobe iironcluis is not seen, which would lead one to think 
 that it is out of the direct route of the invader. To some extent, how- 
 ever, this is also true of the dorsal branches of the inferior lobe bron- 
 chus. The inspiratory air blast eiUering the middle lobe iironchus pos- 
 sibly is not (|uitc so great. It is hoped that future observation will clear 
 up this point. William llruce Smith reiJorts an interesting case of mid- 
 dle lobe brnnrluis invasion. 
 
 Spontaneous expulsion of foreign bodies from the trachea and 
 bronchi. Fortunately for the patient, but unfortunately for other pa- 
 tients, foreign bodies are occasionally coughed u[>. Still more unfortu-
 
 242 FOREIGN BODIES IN LARYNX AND TRACHEA. 
 
 nate is the fact that no distinction ordinarily is made between a foreign 
 body coughed out of the lar\'nx and the much rarer event of one coughed 
 up from the bronchi. It is for the latter reason that statistics are al- 
 most valueless. There have been too few cases of spontaneous expul- 
 sion where the location of the intruder was precisely known. Man- 
 ifestly the expulsion of a large, light foreign body in the larynx or sub- 
 glottic trachea is no basis for deduction as to a specifically heavy foreign 
 body in a minute bronchial branch at the periphery of the lung. In 
 these days of safe and easy bronchoscopy with an enormous percentage 
 of .successes, no one, who is well informed, for one moment considers 
 the advisability of waiting for a foreign body to be coughed up ; but in 
 the event of bronchoscopy failing to remove the intruder, the very high 
 mortality of thoracotomy for foreign body, together with a certain per- 
 centage of failures to find the intruder by external operation ; and, 
 furthermore, as there may be present at consultation someone who will 
 recite a case where the foreign body was coughed up — for these reasons, 
 it is wise to consider the possibilities. The chance of the bechic 
 expulsion of a foreign body depends largely on its nature. Sharp for- 
 eign bodies, such as pins lying point upward, have never been known 
 to be coughed up, for the reason that the pin will stick at the very first 
 angle encountered. On the other hand, smooth, rounded bodies have a 
 tendency to be tightly fixed in the bronchus, and the absorption of air 
 below causes a negative pressure which pulls the foreign body tighter 
 and tighter into the bronchus with less and less air below, and conse- 
 quently less and less chance for expulsion. The patient cannot draw 
 in air enough beneath the foreign body for the expulsive efforts. In 
 the third class might be considered the foreign bodies that are quite 
 heavy, such as bodies of iron, pewter, lead, and the like. These are 
 very rarely ever coughed out because of the little surface they present 
 relatively to their weight. The expiratory blast has not sufficient force, 
 relatively to the surface against which the force is applied, to expel the 
 intruder. We come then to the class of foreign bodies which are not 
 hca\y nor sharp-pointed nor so smooth as to lodge tightly, thus pre- 
 venting air from being drawn below them, and we find such bodies are 
 the most likely to be expelled. The chances are better before than after 
 such a body has reached the smallest bronchus it can enter. It is not 
 so tightly impacted at first unless its size is so large as to nearly oc- 
 clude the trachea or bronchi. In that case it is draw-n in by the in- 
 spiratory blast and accumulates energy on the way according to the well 
 known law of physics. This accumulation is less, directly as the actual 
 weight, and also as the specific weight, except in cases of foreign todies 
 which fit quite closely to the tracheal or bronchial lumen. This ac-
 
 FOREIGN BODIES IN LARYNX AND TRACHEA. 843 
 
 cumulated energy in travel cannot occur in expulsion until after impac- 
 tion is released, because it does not l)csi;in until the body bas begun to 
 move. Hence there is a great disadvantage in expulsion as compared to 
 inhalation of a foreign body. This is not sufiicient to overcome the 
 relative advantage which should accrue from the fact that an exjjulsive 
 effort in coughing is very much greater in jiower than any inspiratory 
 effort can be, the difference being probably twice as much in a coughing 
 expiratory pressure. Then we have the absorption of air drawing the 
 foreign body downward in the case of round foreign bodies which fit 
 the bronchial lumen, either at first or after swelling has taken place. 
 This accounts for the fact that corks and similar substances, though of 
 low specific weight, are rarely coughed up. Pins almost invariably enter 
 the air passages point upward and the point constitutes a ratchet-like 
 mechanism which resists any other movement than downward ; and 
 moreover, the pin offers but little surface upon which the expiratory 
 blast in coughing may act. Furthermore, to get out at all, it must pro- 
 ceed with its long axis more or less in the axis of the passage through 
 which it must go. .Anyone who will attempt to throw any sort of a pin 
 ])oint first, will find that the head of the pin, being heavier, very 
 promptly begins to turn round in advance of the point. With prac- 
 tically all i)ins this would be impossible in expulsion through the air 
 passages for want of S])ace, and the turning would cause the point to 
 stick even if the passage were straight. On the contrary, a number of 
 bends and turns have to be accomplished. l'"or tiiese reasons, a pin 
 that has gotten down to the bifurcation or below, practically never is 
 coughed up, and if it is in the trachea it is almost certain to reach the 
 deeper air passages in a very short time by the combined action of grav- 
 ity and the ratchet-like action of the ])oint. Another factor against the 
 coughing up of a foreign body is that of gravity. This led in the pre- 
 bronchoscopic days to the holding up of the patient by the heels in order 
 to let the foreign body fall out. This was occasionally successful within 
 a few days of the accident, though it sometimes caused a spasm of the 
 glottis and demanded immediate tracheotomy. ( )f course such a pro- 
 cedure is not to be considered in these days of bronchoscopy ; but the fact 
 that it sometimes succeeded indicates the efl'ect that gravity has in in- 
 terfering with the coughing out of foreign bodies. As elsewhere men- 
 tioned, the dog has a vastly more effective mechanism for ridding his 
 bronchi of foreign bodies than is possessed bv human beings. To what 
 extent the more nearly iiorizontal trachea and bronchi of the dog is con- 
 cerned, has not yet been determined. It sccnis prol)ablc. however, that 
 the erect posture of human beings, which is, phylogeneticaliv, verv late, 
 is in a measure responsible for the very inefiicient efforts of nature to
 
 3-14 FOREIGN BODIES IX LARYXX AND TRACHEA. 
 
 cough out foreign bodies. Another factor which favors the inhalation 
 of a foreign body and retards its expulsion is the well known physiological 
 action of the glottis. During inspiration the glottic chink is widened 
 to the maximum, while on expiration it is only partially open and it does 
 not open to the maximum even during the expulsive efforts of the cough. 
 Moreover, the foreign body itself, being driven up against the under 
 side of the vocal cords, or even against the tracheal wall, has a strong 
 influence in exciting reflex contraction which closes the glottis. Still 
 another impediment to the expulsi\e efforts of the cough is the fact 
 that the bronchi contract very greatly during cough and the trachea 
 also contracts to a certain extent. This contraction has been witnessed 
 by every bronchoscopist, as it is one of the difficulties with which he 
 has to contend in bronchoscopy. Perhaps one of the most important 
 factors in the defeat of the bechic expulsion of foreign bodies is the 
 fact that after each coughing effort there is a deep inspiration, during 
 which the bronchi are dilated and the inspiratory blast has the effect of 
 carrying the foreign body deeper and deeper, aided by the negative 
 pressure below. 
 
 In deciding the chance of spontaneous expectoration of a foreign 
 body in the bronchi it is necessary to remember the very inefficient 
 coughing and expectorating mechanism of children. 
 
 Summarizing, we divide for prognostic purposes all foreign bodies 
 into three classes : 
 
 1. Those of high specific gravity. 
 
 2. Those of low specific gravity, ( including hollow bodies with 
 relatively large surface). 
 
 3. Those of intermediate suecific gra\ity. 
 
 In the first class we may tell our patient that there is almost no 
 hope of the intruder ever being coughed up in case of adults and ab- 
 solutely none in infants and very small children. In the second class 
 there is a chance of expectoration in older children and adults, almost 
 none in children, none at all in infants. In the third class of substances 
 the chances of expectoration of the foreign body in either adults or 
 children are remote. Long, thin, pointed and relatively heavy bodies 
 like pins and needles are never coughed up from below the glottis. In 
 any case, the author's later experience confirms his earlier statement 
 (Bib. 2(59) : namely, "We do full justice to our patients when we tell 
 them that while the foreign body may be coughed up. it is verv danger- 
 ous to wait; and. further, that the difficulty of removal increases with 
 each hour the body is allowed to remain." 
 
 Magnetic extraction of foreign bodies. Many of the mechanical 
 problems, and also the problem in certain cases of finding the foreign
 
 FOREIGN HODIKS IN I.XKVNX AND TRACHKA. 2-t5 
 
 body, would be solved if magnetic extraction were feasible. It bas 
 yielded such wonderful results in oiilithalmology tbat its use in bron- 
 choscopy at least seemed worthy of development. Ten years ago the 
 author experimented quite thoroughly and the results of the experiments 
 were published in The Laryngoscope (Bib. 233). Only four of the 
 conclusions need be mentioned here, namely : 
 
 1. The foreign body must be of iron or steel, partly or wholly. 
 
 2. The body must be free to move. 
 
 3. The attraction of the magnet for the foreign body is no greater 
 than that of the foreign body for the magnet, hence : 
 
 4. The probabilities of magnetic removal are directly as the size of 
 the foreign body, within the limits of size i)ermitting mobility. 
 
 It will be seen by the foregoing that the magnet is only useful in 
 precisely those cases which are most favorable for bronchoscopic meth- 
 ods. Unfortunately magnetic extraction does not assist in those cases 
 beyond the limits of bronchoscopy. R. C. Lynch (Bib. 3.50) reports a 
 successful case of magnetic extraction, as does also Iglauer (Bib. 221). 
 
 Mortality and results of bronchoscopy for foreign bodies: In con- 
 sidering the mortality of bronchoscopy, two facts stand out prominently. 
 The first is that we should distinguish between the mortality of the 
 method on the one hand, and the mortality from the lack of prompt- 
 ness and precision in performing it. For instance, the reports of four of 
 the fatal cases show that the patients died upon the table of asphyxia 
 for want of a prompt bronchoscopy. 
 
 Ingals, who is a pioneer bronchoscopist of large experience, writes : 
 "Owing to numerous cases that come to my knowledge where inexper- 
 ienced men have performed bronchoscopy with fatal results, and owing 
 also to my recollection of the difficulties I experienced in the beginning 
 of this work, I think it is highly desirable that some statement be made 
 which would deter the inexperienced from undertaking these operations 
 needlessly. I believe the fatalities witii inexperienced people would run 
 between Id and 20 per cent if all cases could be collected." 
 
 \'on Eicken collected 300 cases of bronchoscopy for foreign bodies 
 up to and including the year litOS. The total mortality from all causes 
 is given as 13.1 per cent. His statistics show for the [)re-bronclio- 
 scopic period, 'rZ per cent. This brought into strong contrast the won- 
 derful results of bronchoscopy even in the hands of beginners, as many 
 of the cases were, and is a tribute to Killian, the father of bronchoscopy. 
 The statistics of li'oii and litio were collected by Kahler, consisting of 
 2!)1 cases with a mortalitv of 27. making li.(i |)er cent. Of this mortal- 
 ity, not a single case could be attributed directly to bronchoscopy, but 
 rather to the results of the foreign body itself or of blind methods of
 
 24G FOREIGN BODIES IN LARYNX AND TRACHEA. 
 
 removal attempted prior to the bronchoscopy. The statistics of these 
 two years, as compared with those collected by Kahler of the time prior 
 to 1909, show clearly the improvement in technic and instruments, as well 
 as in the personal skill of the various operators. As Briinings points 
 out, if it is desired to get at the exact mortality of bronchoscopy per se, 
 it will be necessary to include in statistics only the cases in which the 
 foreign body has not been long present, because of the secondary changes 
 that take place after a more or less prolonged sojourn of the foreign 
 body. In preparing a "Rapport" for the International Medical Congress 
 (Bib. 270), the author collected 171 cases of bronchoscopy for foreign 
 bodies done in the United States ( European statistics being in charge 
 of the co-rapporteur, Prof. Killian) by \arious operators. In the 171 
 cases there were nine deaths (.5.3 per cent J. This does not include four 
 deaths due to asphyxia for want of promptness in performing bron- 
 choscopy. Of these, lot! were removed, 14U by peroral bronchoscopy, 
 23 by tracheotomic bronchoscopy. Of the fifteen unsuccessful cases, 
 twelve were failures to find the foreign body known to be present, and 
 only three were failures to remove it when found. In the twelve cases 
 mentioned as failures to find the foreign body are included four in 
 which the foreign body had been seen when higher up. After escaping 
 into the deeper, minute bronchi it could not be re-located bronchoscop- 
 ically, though still showing in the radiograph. The statistics of the 
 author's own clinic and of his cases elsewhere, which are not included 
 in the foregoing, are as follows : Of the last 182 consecutive cases of 
 bronchoscopy for foreign body there was a total of three deaths (1.7 
 per cent) from any cause whatever within one month, though a few of 
 the cases could not be followed this long. Of the 183 cases all were 
 peroral bronchoscopies. Of the 182 cases, the foreign body was removed 
 in 177. Of the five failures to remove foreign bodies known to be 
 present, all were failures to find a small foreign body that was in a small 
 branch bronchus close to the periphery of the lung. Two of these cases 
 were recent. The percentage of the author's failures will doubtless in- 
 crease in the future, since he now gets the cases upon which others have 
 been unsuccesful and doubtless he will be equally so ; though he has 
 hopes that the elsewhere mentioned recently perfected means of locating 
 small bodies in small bronchi near the periphery will diminish for every 
 one the number of cases in which the intruder cannot be found. 
 
 Indications for bronchoscopy in suspected foreign body cases. It 
 would be a mistake to elaborate many fine points of distinction as to the 
 indications for bronchoscopy in suspected foreign body cases for -three 
 reasons: (a) A foreign body ma\' be present without any demonstrable 
 signs or symptoms, (b) In all cases of doubt a bronchoscopy should
 
 FORKICN r.ODir.S IX LAKVNX AM) 1RACHKA. 247 
 
 be done anyway, (c) Disease may be found to account for foreign 
 body symptoms. The first two reasons are so abundantly proven as to 
 need no citation of cases. The third reason (c) may be supported by 
 two cases selected from among a number because the bronchoscopic 
 diagnosis was of fundamental therapeutic importance. A man of forty 
 years was referred to the author for removal of a wooden toothpick 
 which was thought by the patient to be the cause of a cough of sudden 
 on.set following "cjioking on a toothpick." No foreign body was found 
 but an indurated ulcer at the carina lead to a diagnosis of lues which 
 was verified later. Mr. H. J. Davis reports an interesting case in which 
 a fourteen-year-old child insisted that she could feel a pin in her chest. 
 The radiograph was negati\e but on passing the bronchoscope he found 
 a diphtheritic membrane in the trachea though none was present higher 
 up. 
 
 Acute disease, such as the bronchopneumonia of children and unex- 
 plained "edema of the lungs," may in a few cases suspected of foreign 
 body origin be indications for bronchoscopy. 
 
 The simulation of tuberculosis, chronic pleurisy with effusion, bron- 
 chitis, asthma, bronchiectasis and other chronic lung affections by pro- 
 longed sojourn of a foreign budy renders bronchoscopy indicated in cer- 
 tain cases of these diseases. Instances have been reported by the author 
 and others where these diseases have actually arisen secondarily to the 
 presence of a foreign body. Of course it is not meant to urge bron- 
 choscopy for foreign bodies in all cases of the diseases mentioned except 
 bronchiectasis ; but bronchoscopy is indicated in any case where there is 
 a possibility of foreign body origin and in certain cases it is indicated for 
 assistance in diagnosis and treatment of the diseases independently of a 
 foreign body element. A radiograph may confirm or negative the indica- 
 tion. This matter is more fully considered in connection with the prob- 
 lems presented by bronchial foreign body cases of prolonged sojourn. 
 The various indications for bronchoscopy in suspected foreign body cases 
 may be summed up as follows, though this is by no means a complete 
 category : 
 
 1. The appearance, in the radiogra])h, of a foreign body or of any 
 suspicious shadow. 
 
 2. In any case in which there is a clear history of the patient hav- 
 ing choked on a foreign body, and in wliicii the foreign body was not 
 afterwards found. 
 
 In this coimection, it must be borne in mind tiial f(jreign bodies 
 ma\ be nuiitiple, as in one case of the author, in which a bronchoscopy 
 was not done because after the accident a gourd seed was found in the
 
 248 FORKIGN r.ODIK.S IN I.ARVNX AND TRACIIKA. 
 
 Stools. I'hree months later he removed a gourd seed from the bronchus. 
 The child had been playing with a whole mouthful of gourd seeds. 
 
 3. In any case in which there are signs of stenosis of the trachea 
 or of a bronchus. 
 
 4. Any case suspected of bronchiectasis. 
 
 5. In the absence of anv foreign body history, the patient giving 
 symptoms of pulmonary tuberculosis, in which the bacilli cannot be found 
 in the sputum and especially if the physical signs are at the base, par- 
 ticularly the right base, and above all, if there are also physical signs of 
 pleural effusion. 
 
 (i. In case of doubt, bronchoscopy should be done anyway. 
 
 Contra-indications to bronchoscopy for foreign bodies. The author 
 has had no cause to modify his views previously expressed (Bib. 269), 
 namely, that there is no absolute contra-indication to bronchoscopy. 
 In some cases of extreme exhaustion, for instance when a patient who 
 has already had too many bronchoscopies, it may be advisable to delay 
 until the patient recuperates. Pneumonia of any form is certainly no 
 contra-indication. It has been the author's custom to remove the foreign 
 body even at the height of pneumonia, and invariabh- the influence of the 
 removal of the foreign body has been good, rather than otherwise. Pul- 
 monary abscess and other local lesions due to the presence of the foreign 
 body itself, far from being contra-indications, are indications of the 
 strongest kind for immediate bronchoscopic removal of the intruder. 
 Gangrene of the lung is not a contra-indication to bronchoscopic removal 
 of a foreign body unless the patient is moribtmd. Gtiisez has success- 
 fullv treated gangrene of the lung bronchoscopically. It goes withottt 
 saying that if the patient is dying from obstruction due to the foreign 
 body, an immediate bronchoscopy is indicated; but if the patient is mori- 
 bund from other causes, bronchoscopy is contra-indicated until the pa- 
 tient has rallied. Serious organic disease, such as aneurysm, does not 
 constitute an absolute contra-indication, for unless the patient's immedi- 
 ate condition is serious from the aneurysm, he will live longer with the 
 foreign body out than in. The author has had three foreign body cases 
 in each of which a diagnosis of the vague syndrome called "status lym- 
 phaticus" had been made by a competent internist, and yet nothing vm- 
 usual was noticed at the bronchoscopy, nor afterward. In a number 
 of other foreign body cases a slight degree of thymic compression was 
 noted incidentally at bronchoscopy. Xo anesthetic was used in any of 
 these cases. The author quite agrees with Clark that "status lymphat- 
 icus" is no contra-indication. When a patient is in bad general condi- 
 tion, but not dyspneic, the question arises whether it is wise to wait for 
 the patient to recuperate before doing the bronchoscopv for removal.
 
 FORKICN BODIES IN LARYNX AND TRACHKA. 349 
 
 Tlic situation is best illustraleil by tbe following case: Three days after 
 having aspirated a pin, an infant was sent from a distant city where it 
 iiad been subjected to an oral bronchoscopy of one hour's duration, fol- 
 lowed Ijv a tracheotiimy and a tracheotomic bronchoscopy of two hours' 
 duration on the day after having aspirated the pin, involving an ether 
 anesthesia of one hour's duration the first day and of two hours' duration 
 the second day. Then it was subjected to a day's travel. W hen the 
 child arrived it was ijuite e.\hausted from the various ordeals and the 
 interference with regular nutrition. The question arose whether under 
 these circumstances it were better to do the bronchoscopy at once or 
 to wait for recuperation. The only objection to waiting was that the 
 difficulty of removal usually increases steadily with each day that elap.ses 
 after the inspiration of a \'ery minute foreign body into a very small 
 bronchus. For this reason, immediate bronchoscopy was decided upon 
 and successfully executed through the mouth. There was no increase 
 in the exhaustion and the child rallied well and was sent home a few 
 days later. Had the foreign body been of larger size, instead of in a 
 small broncinis which could have easily swollen shut by a few days 
 longer wait, the author and his medical advisors would have decided on 
 waiting for the child to rallv before subjecting it to any further ordeal 
 Fortunately, we were able to do the work without anesthesia. J lad a 
 general anesthetic been retjuired, it doubtless would have involved very 
 great risk in the exhausted condition of the child. Had dyspnea been 
 present, of course immediate bronchoscopy would have been obligatory 
 and no (|uestion of delay could have been considered for one moment. In 
 view of such experiences as these, tbe author feels that the (|ueslion 
 should be decided on the following basis: In cases without dyspnea, 
 where a large foreign body is present in a child very much exhausted 
 from any cause, it is better to wail, under careful watching, for recu()era- 
 tion : and if general anesthesia is to be used, it is quite imperative to 
 wait. If. on the other hand, the foreign body is of the nature of a small 
 pin or needle that has invaded a very small bronchus far out toward 
 the jjeriphery of the lung, it is better to proceed at once without any an- 
 esthesia, general or local. If there is dyspnea present, immediate bron- 
 choscopy is absolutely imperative, and it must be done, without anv an- 
 esthesia, general or local. We are, of course, speaking of children only: 
 in adults there would be little or no danger in the use of a local anes- 
 thetic. In ]iassing, it may be mentioned that in cases such as the one 
 cited above, the inefficiency of the infantile cough in the remoxal of se- 
 cretions must be borne in mind as mentioned under "Drowning of the 
 patient in his own secretions."
 
 250 FOREIGN BODIES IN LARYNX AND TRACHEA. 
 
 Choice of time to do bronchoscopy for a foreign body. The choice 
 of time to operate is as soon as possible after the accident. The difficul- 
 ties of removal increase steadily from that time onward. The bronchi 
 will swell shut and the orifices will be entirely obliterated temporarily 
 by edema, later by the organization of granulation tissue, or the granula- 
 tion tissue will, by its bleeding, render much more difficult the bronchos- 
 copic removal, or the secondary changes, such as strictures, will enor- 
 mously increase the difficulties. The patient's health will deteriorate, 
 making him a less favorable subject for bronchoscopy, and occasionally 
 the foreign body may escape from the bronchus into the tissues, though 
 this is a rare accident. In case of bodies liable to exj)and or become 
 friable by absorption of moisture, as dried beans, peas, maize and the 
 like, every moment lost decreases the patient's chances. This does not 
 justify hasty or ill-planned efforts without equipment ; but, as Emil 
 Ma\er says, "Such a patient should be looked upon as constituting an 
 emergency case to be operated upon at once." Solid bodies that by 
 their shape are apt to occlude a bronchus, even though they do not 
 swell, are to be operated upon at once, also, because of the serious effect 
 of atelectasis and stagnation of secretion below the intruder, and, most 
 important of all, because of the drawing downward of the foreign body 
 by negative pressure which, with the swelling of the mucosa above as 
 shown in Fig. 182, makes removal more and more difficult the longer 
 the delay. 
 
 The duration of a bronchoscopy. Endoscopists are now agreed that 
 prolonged bronchoscopy in children is inadvisable and that a number of 
 shorter sittings is safer. This has no reference to the ques- 
 tion of subglottic edema which will be sei)arately considered. The 
 author has frequently prolonged bronchoscopy to one hour's duration in 
 children ; but as a rule, a half hour from the time the bronchoscope 
 passes through the larynx, should be the limit except in exceptional in- 
 stances, in a child under two years of age. Over two years of age, a 
 bronchoscopy of an hour, without anesthesia, general or local, is prac- 
 tically without risk. Drug shock, especially the paralyzing effect mor- 
 phine and chloroform have on the respiratory center, renders a bronchos- 
 copy of over fifteen minutes' duration hazardous. In an adult, the author 
 has, in one instance, prolonged the bronchoscopy to three and a half 
 hours, using a very little bit of cocaine solution a number of times, ap- 
 plied only to the neighborhood of a foreign body in the bronchus. 
 
 This matter of duration is so important, and is so greatly influenced 
 by various factors, that it is quite necessary for bronchoscopists to re- 
 cord the duration of their endoscopies in order to get data for a work- 
 ing basis. The author has such a record for most of his cases.
 
 I'ORKICX BODIHS IX I.ARVNX AND TRACHEA. 251 
 
 The endoscopic appearances of foreign bodies in the air passages. 
 Those who have never tried it may not realize that the endoscopic de- 
 tection of a foreign body is, even when presented, not always easy to 
 the inexperienced. Prolonged training will enable the experienced endo- 
 scopist instantly to recognize any departure from the normal, even though 
 the exact nature of the condition may not be at once realized. This 
 is a valuable time-saving acquisition to be striven for. It must be re- 
 m.embercd that, as is well known to all artists, color depends largely 
 on the intensity, quality and direction of the illumination. Moreover, it 
 is often not the true color of the foreign body itself that presents, but 
 the foreign body as seen through a filmy coating of secretions which may 
 be tinted with pus, blood or dissolved material from the foreign body 
 itself. Therefore, the lube must be advanced slowly and carefully, all 
 secretions being sponged away ahead of the tube-mouth so that the z^'all 
 as well as the lumen can be carefully studied, not for the foreign body 
 alone, but for evidences of traumatism or inflammatory lesions due to 
 its presence. As stated above, the color of a foreign body as seen endo- 
 scopically, varies with the degree of illumination. As a rule, however 
 iron and steel bodies look black even after a few days' sojourn, no 
 matter how highly polished they may have been when they entered. 
 Xickel-plated objects, as a rule, do not tarnish so readily. Silver ob- 
 jects turn black very quickly, just as steel and iron bodies do. Brass 
 substances corrode quickly and soon look dark brown or black. The 
 glint even of nickel-plated Ijodies is soon dulled by secretions, so that 
 taking it all in all, the endoscopist will usually find all sorts of foreign 
 bodies to be grey, or, more often, almost black in color, with the excep- 
 tion of very recently aspirated brass, gold and bright copper substances, 
 which may show for a few days in nearly their natural colors. As a rule, 
 however, the bronchoscopist who is looking for a brightly shining, whit- 
 ish glint will be deceived by the refraction of air bubbles and the spurs 
 at the giving off of the different branch bronchi. As pointed out by 
 Waggette (Bib. '>(u). it is necessary urgently to warn the beginner 
 not to mistake the shar[), white, cartilaginous division between two 
 branches for a foreign body. With a corroded steel or iron body, show- 
 ing black, this is not likely t(j occur; but if the operator has in mind the 
 bright silvery whiteness of the ordinary ])in, for instance, he is very apt 
 to make such a mistake as Mr. Waggette warns against. As shown by 
 U. i\. Patterson (Bib. l.'Sll), the natural color of a foreign body mav be 
 such as to render its contrast with the surrounding mucosa so slight 
 as to make j)rom])t recognition difficult. This is an important point to 
 keep in mind.
 
 252 FOREIGN BODIES IN LARYNX AND TRACHEA. 
 
 Bronchoscopic finding of a foreign body in the traeheo-bronchial 
 tree. Finding a large foreign body recently aspirated presents no espe- 
 cial difficulties. One of long sojourn may be hidden by secondary pro- 
 cesses ; and the problem then presented will be separately considered. 
 Small foreign bodies are in some cases very difficult to find. Xot be- 
 cause of any difficulty in seeing a minute object when such objects can 
 be brought in line with the observer's eye, but because small foreign 
 bodies may be located "around the corner" in a small branch bronchus, 
 into which we do not directly look. When a small foreign body, such 
 as a needle or a pin, has penetrated a small bronchus, there may be se- 
 cretions emerging from the little bronchial branch that will betray the 
 presence of the pin, but quite as often there is nothing in the way of 
 local appearances to guide. Under such circumstances, the methods of 
 localization referred to in a previous chapter should be used to limit 
 the number of bronchi to be searched to a very few. In the absence 
 of such means, it certainly is not justifiable to search every bronchus in 
 the entire lobe, and still less is it justifiable to go with the forceps or 
 probe into every bronchus. Having narrowed down the number of small 
 bronchi to be searched to a few, each of the few orifices must be looked 
 into in the manner shown in the schema Fig. 172. The bronchoscope, 
 J;!, is introduced as far as possible into the inferior lobe bronchus and the 
 endoscopist sees ahead the orifices of two or more branches, (D.) none 
 of which, however, shows any evidence of invasion of the pin, which is 
 below the level of the \isual axis, and is hidden by the intervening tissue, 
 C. When we have reason to suspect such a condition of afi'airs from 
 the radiographic localization, either by the radiograph with film overlay, 
 or by radiograph with the bronchoscope in position, the 
 tissue. C, must be pushed backward out of the way by the lip of the 
 bronchoscope. In doing this, it is necessary to raise the head of the 
 patient and in certain instances it will be necessary to raise the head 
 and shoulders, the head being flexed forward on the thorax. In this 
 position, the bronchoscope, as shown at ^I. will afl:'ord a view of the 
 point of the pin (E.). The large amount of resiliency of the bronchial 
 tissues permits of such manipulation without injury, provided the manip- 
 ulations are gentle. It is very easy to rupture a bronchus by pushing 
 the tube with too much pressure into a bronchus not sufficientlv large 
 to admit the tube. Blind probing for exploration of bronchi suspected 
 to contain the intruder is dangerous unless done with extreme caution. 
 If any orifice seems at all suspicious the conical-ended bronchoscope 
 (Fig. IS) may be used, or a closed, plain, straight forceps (Fig. 28) 
 may be introduced carefully as a probe. If the intruder is felt the for- 
 ceps jaws may be expanded and the foreign body seized, but great care
 
 FOREIGN HODIKS I.N I.ARVNX AND TRACHEA. 
 
 253 
 
 must be used. Under no circumstances should strong traction be made. 
 In minute bronchi a foreign body is rarely firmly fixed because its 
 distal part is necessarily small or it could not have entered. If a spur 
 between two bronchial openings is grasped, slight traction will give an 
 elastic sensation that can readily be recognized as quite different from 
 the yielding of a foreign body that is free to move. Of course, a pin 
 whose point is upward, as practically all are, may stick into the bron- 
 chial wall, preventing withdrawal. This would give the same sensation 
 of elasticity, which is due to the elastic mobility of the lung. This blind 
 
 ! Hf:!'--; 
 
 Fig. i~2. Schema illustrating the author's method of bringing into view a 
 pin (A) located "around tlic corner," and hidden by the tissue (C) from the ob- 
 server, who, in looking through the bronchoscope, B, sees only empty orifices (D). 
 Ry raising the patient's head very high, the lip, L, of the bronchoscope displaces 
 the tissue, C, permitting the ob.server to see the point of the pin as at E. The 
 schema was drawn by the author after thus finding a pin in a small dorsal branch 
 of the inferior lobe bronchus. He has used the principle many times since in 
 branches diverging at various angles and twice in the upper-lobe bronchus. 
 
 groping is dangerous. Particular care must be used not to mistake 
 the grating sensation of the probing force])s sliding over the inner wall 
 of the bronchoscope for the contact of a foreign body. Under no cir- 
 cumstances is it justifiable to use toothed forceps for probing. 
 
 When a pin is located so as to have its long axis corresponding to 
 tlie long axis of the bronchoscope, the point of the pin presenting toward 
 the o])erator. the i)in may be difficult to see. though as a rule there is 
 movement enough to the whole tree to throw the pin at various angles 
 so that it is only for a moment that the pin's axis exactly coincides with 
 llie visual axis. I'sually als". the color of the pin is black from cor-
 
 254 rOREIGX BODIES IX LARYNX AND TRACHEA. 
 
 rosion. A very recently aspirated bright ])in may. however, be mistaken 
 for a string of mucus or a division spur. Aluch more often, however, 
 the reverse mistake is made ; the white line of a spur, or a thread of 
 mucus is thought to be the foreign body, until the eye has become edu- 
 cated to these illusions. 
 
 It is a mistake to be constantly withdrawing and inserting the bron- 
 choscope. The author in 208 cases of foreign body in the bronchus did 
 not remove the bronchoscope in a single instance until entirely through 
 with the bronchoscopy. This is not mentioned boastfullv but to correct 
 the prevalent misunderstanding of the subject. The author cannot 
 bring to mind any reason why. starting with a properly selected tube, 
 the bronchoscope should be removed. It is a time-wasting procedure 
 even if it does take but a few moments. If there should be any trouble 
 with the light, the light carrier can be withdrawn ; but this should not 
 be necessary more often than once in thirty or forty cases ; and not 
 oftener than once an hour in any case. Properly illuminated, the life 
 of a lamp is about 40 hours. The sponging away of secretions from 
 the field keeps the lamp clean at the same time, as previously explained. 
 
 Negative endoscopic findings in foreign body cases. Many cases 
 come to the endoscopist erroneously believing that a foreign body has 
 lodged in their anatomy. These cases may or may not need endoscopic 
 search as herein elsewhere indicated ; but if searched it should be thor- 
 oughly done. There is another class of negative cases, in which the 
 foreign body has probably been present at some time or other. These 
 recjuire very careful work. In the trachea and bronchi, evidence, in the 
 form of local reaction, justifies the most careful and persistent search, 
 because the chances are all in favor of the foreign body still being pres- 
 ent, possibly hidden in swollen mucosa or in a closed-off bronchus, either 
 of the same side or even on the other side. In other words, traumatism 
 or reaction found in a bronchus indicates that the foreign body is pres- 
 ent, but it does not necessarily localize it to the side on which the 
 traumatism is seen, because of the well known tendency of foreign bodies 
 that are free to knock in the air passages to be aspirated into the op- 
 posite side. In all cases of doubt as to the localization of the foreign 
 body we must do a bronchoscopy as well as an esophogoscopy, doing 
 first the one indicated by the preponderance of evidence. Furthermore, 
 in any case where all the data point almost conclusively to the foreign 
 body being in the esopliagus or in the air passages, as the case may be, 
 and failing to find it in the search of the one, we must then search the 
 other before giving a positive opinion that a foreign body is not present, 
 because none of our diagnostic means are absolutely reliable negatively. 
 In the esophagus both pyriform sinuses and the sub-cricopharyngeal
 
 FOREIGN BODIES I.N LAKVNX AND TRACHEA. 255 
 
 space must be searched with a large tube or speculum. The possibility 
 of sharp-pointed bodies having wandered out through the esophageal 
 wall must be borne in mind. Such bodies usually are metallic and hence 
 radiograph ically discoverable; but occasionally a rib bone of a fish w-ill 
 thus wander and will not show. The author had one such case, also a 
 case of a toothbrush bristle. In none of these was an esophagoscopy 
 done. Mr. E. D. Davis reports the case of a boy with a pin that could 
 not be found esophagoscopically, but which seemed, radiographically. 
 to be in the retropharyngeal space. In conclusion we may say that no 
 case can be considered to have been endoscopically explored unless the 
 trachea, right and left, main, inferior and upper bronchi and the middle 
 lobe bronchus (present on the right side only) shall have been examined, 
 to the greatest depth reachable. Nor are wc ready to give a negative 
 o[)iiiion then. The hypopharynx and esopliagus must be explored from 
 the arytenoids to the stomach. This, however, must not be misconstrued 
 into achising that thorough exploration must be completed at one seance. 
 
 Inasnuich as we know that certain foreign bodies, such as small pins, 
 may be present in the bronchi, as shown by the radiograph, and yet not 
 be discoverable by bronchoscopy, how shall we be certain, in case of 
 a foreign body not opaque to the ray, that it is not present on the strength 
 of not being able to find it bronchosco])ically. If the foreign body is of 
 such small size that it can enter a small lir(jnchus far out at the peri- 
 j)hery. it is impossible to be certain. If, on the other hand, the history 
 mentions a nonfriable foreign body of such size that it cannot enter a 
 bronchus too small for a bronchoscope to follow it. we ma\' be certain, 
 after a careful search, that it is not jjresent if not found. If the body is 
 liable to be comminuted by maceration this does not hold absolutely 
 true. ( )ne other point which will aid sometimes in deciding the question 
 is that we may be able to state from the apix-arances of reaction around a 
 small bronchus, that it probably contains a foreign body. This is only 
 available, however, when there has been no previous bronchoscopy which 
 could have caused irritation by probing that bronchus, and of course the 
 error must be avoided of mistaking traumatism of a foreign body which 
 had been coughed up for the traumatism of the reaction of a foreign body 
 which is still present. 
 
 Oral or tracheotomic bronchoscopy. Which/* Unfortunately the 
 statement has crept into the literature that in infants or small children 
 it is |)reUTabk' to do a tracheolomic bronchoscopy. In the opinion of 
 the author this is due to twcj tilings: 1. The ignoring of the precautions 
 mentioned under subglottic edema. 2. The fact that when this statement 
 
 •Abstracted from the author's Rapport at the International Medical Congress, 
 London, 1913.
 
 256 FOREIGN BODIES IN LARVNX AND TRACHEA. 
 
 was originally made, illumination was not in the relatively perfect condi- 
 tion that is seen on the instruments of to-day. In making this state- 
 ment, the author hopes he will not be misunderstood as referring to any 
 difference between distal and proximal illumination. He means simply 
 that the light on all forms of instruments to-day is far superior to what 
 it was in the early days. At that time it made a great difference whether 
 the tube was a long or a short one. To-da\ , it is questionable whether 
 anyone can tell by looking through the lumen whether the tube is 30 
 cm. or 50 cm. The author has often tested this and found the ob- 
 server unable to tell with a pair of concealed tubes which was the longer 
 and which was the shorter, even though one was an 80 cm. gastroscope. 
 Therefore, a short tube has no advantage so far as illumination is con- 
 cerned. In regard to the manipulation of forceps, etc., an additional 
 length of 10 to 11 cm. is of no advantage whatever. It is true that a 
 somewhat larger tube can be used through a tracheotomic wound than 
 through the glottis with safety to the subglottic structure, but Dr. Ellen 
 J. Patterson and the author have found that a tube of 4 mm. internal 
 diameter is amply large for delicate manipulations under the guidance 
 of the eye, such as the placing of a hook through the eye of a shoe-but- 
 ton in the bronchus of a child six months of age. If one is not accus- 
 tomed to work through small tubes, doubtless it is better to do a 
 tracheotomic bronchoscopy than to force a large tube through the larynx. 
 In upper lobe bronchoscopy, almost as favorable an angle can be ob- 
 tained by shifting the tube to the opposite corner of the mouth, as 
 could be obtained by a tracheotomic bronchoscopy, provided the assist- 
 ant holding the head, and the operator have worked years together so 
 that they co-operate and the head of the patient is carried along with 
 the tube to the extreme opposite position from the lobe to be explored. 
 All of these things are readily demonstrated on the patient, but unfor- 
 tunately the statements in the early literature have led men into hasty 
 tracheotomy rather than to develop the necessary technic to work with 
 exceedingly small tubes and to axoid damage to the subglottic area 
 Out of 71 Hi bronchoscopies for all purposes, no one in the author's clinic 
 has ever done a tracheotomy for the purpose of bronchoscopy. One 
 tracheotomic bronchoscopy done by the author for a foreign body was 
 in a case where the general surgeon had already done a tracheotomy for 
 the compressive stenosis due to a goitre. In that case the author failed 
 to find the foreign body, a small jiin. In one other case, also in his 
 early work, he did a treacheotoniic bronchoscopy in a foreign body 
 case tracheotomized for dyspnea. Both cases failed to convince the 
 author that there is any advantage in the tracheotomic route. With 
 these two exceptions, it has always been our custom to insert the bron-
 
 FOREIGN P.ODIF.S IX LARVXX AXD TRACHEA. 257 
 
 choscope through the inouth. even in the cases already tracheotomized 
 for dyspnea. \'ery often i)atients come in with such severe dyspnea 
 that it is unwise to leave them over night without a tracheotomy. In 
 such cases, the absolute rule in tracheal surgery to do a tracheotomy 
 always early, never late, is followed ; but in the first management of 
 the case we have always found that a bronchoscope introduced through 
 the mouth is much better for the temporary relief of dyspnea, insuffla- 
 tion of oxygen, etc. In foreign body cases previously tracheotomized 
 the bronchoscope introduced through the mouth we have found much 
 more freely manipulated and much more satisfactory to work with be- 
 cause the patient's head is very much less in the way, and all of the 
 movements and manipulations are the usual ones in peroral endoscopy. 
 The author hopes the foregoing will not be regarded as boasting. 
 He feels sure that other endoscopists just simply have not tried oral 
 bronchoscopy in infants, but have been misled by early statements based 
 upon different conditions, and especially different instruments. The 
 production of subglottic edema by oral bronchoscopy in children was 
 due to faulty position, too large tubes and other preventable factors 
 that will be considered in a later section. The preference of some op- 
 erators for tracheotomic bronchoscopy has been due to the erroneous 
 position of the head used in oral lironchoscopy. As elsewhere mentioned, 
 the direction of the trachea is backward as well as downward. It fol- 
 lows that a tube introduced through the anterior part of the neck will 
 necessarily be of a great advantage compared tc a tube which is intro- 
 duced through the mcjuth if the head of the patient is very low. If, on 
 the other hand, the head ( recumbent 1 is very high, there is absolutely 
 no advantage in direction in the tracheotomic route. The head has 
 usually been held too low in oral bronchoscopy. Figure 1G3 illustrates 
 the needlessness of tracheotomy so far as reaching a foreign body is 
 concerned (it was necessary in this case for other reasons). The 
 bronchoscope shown in the radiograph is passed through the mouth 
 and shows the bronchoscope at a farther angle toward the periphery 
 than was necessary to reach the pin. .A tracheotomy had been done by 
 ihe previous operator in the hope that a tracheotomic bronchoscopy might 
 succeed when he failed at an oral bronchoscopy. The author worked 
 through the mouth only, and while he was equallv unsuccessful in 
 finding the pin, the point here made is that so far as reaching a foreign 
 body is concerned there is absolutely no advantage in angle by the 
 tracheotomic route. The radiograpli was not made for the purpose 
 I if denionstraliiin but as an aid to the working out of the problems in 
 that [)articular case, llad demonstration been the object, the distal end 
 of the bronchoscope coukl easily have been mo\ed out to the patient's
 
 258 FORKIGN BODIES IN LARYNX AND TRACHEA. 
 
 left beyond the heart shadow, there being absolutely nothing in the 
 oral route to prevent such an angle. So far as any advantage in lateral 
 movement is concerned, the error has been made of not realizing the 
 wide range rendered available by the Boyce position. The range is 
 shown schematically in Fig. lo.") and actually in the living patient in 
 Figures l;Jii and 1115. Sharp foreign bodies, especially those with hooked 
 extremities, or such as may retjuire a complicated procedure for re- 
 moval, do not demand a traclieotomy, but simply more careful work. 
 In the hands, however, of the endoscopically inexperienced, it is per- 
 fectly justifiable in such cases to do a tracheotomy; and it should by 
 all means be done in preference to rough and violent removal after an 
 indiscriminate forceps seizure of the foreign body at any point that 
 may present. Extremely large foreign bodies do not necessarily demand 
 tracheotomic bronchoscopy. .Any intruder that has gone down through 
 the glottis can be brought up the same way, if turned to the position 
 of least resistance. Thymic tracheostenosis, thyroid anomaly, acute or 
 chronic laryngeal stenosis and many other conditions may demand 
 tracheotomy and the author would be the last one in the world to argue 
 against its prompt and early performance. But in this chapter are pre- 
 sented reasons wh)- it is needless for the passage of a bronchoscope. I ^ 
 conclusion the author would strongly urge the bronchoscopist not to 
 resort to tracheotomic bronchoscopy at the second trial. If the first bron- 
 choscopy is not successful after fifteen or twenty minutes in a child it is 
 better to desist, wait a few days and repeat the oral bronchoscojjy at 
 least twice before resorting to the tracheotomic route. The author feels 
 sure that a large number of the reported cases where the first bron- 
 choscop)- was oral and the second, tracheotomic, the second broncho- 
 scopy would have been just as successful if it also had been oral. On 
 the other hand, the author regards tracheotomy as perfectly justifiable 
 in any case in which the surgeon in charge deems tracheotomy for any 
 reason whatsoever indicated for the best interests of the patient. In 
 stating his personal views he recognizes the advisability of everyone de- 
 ciding such ([uestions for himself, apropos of the particular case. 
 
 COMPLICATIONS AND AFTF.R-F.FFlXTS OF BRONCHOSCOPY. 
 
 After-care in endoscopic foreign-body cases. All foreign-body cases 
 should have a special nurse night and day so that a careful watch may 
 he maintained at all times. The possibility of the patient drowning in 
 his own secretions, or of respiratory arrest, should be borne in mind and 
 under no circumstances whatever should the ]iatient be permitted to 
 leave the hospital before all danger of complications is over. In the 
 majority of cases the patient could go home the same evening without
 
 KORKir.N liOniES IX LAKVNX AND TRACHKA. 
 
 259 
 
 injiirx' Init occasidiially ci implications may occur and it is better to he 
 on the safe side. 
 
 General reaction. There is in the majority of instances no gen- 
 eral reaction followine; a hronchoscopy in a patient whose temperature, 
 pulse and respiration are normal at the beginning. Occasionally there is 
 a reaction to 100' F. The chart in such a case is reproduced in 
 Fig. 17o. If, however, bronchopneumonia, septic pneumonia and other 
 
 Fig. 17.^. Chart of a niaxinmtii reaction seen after bronchuscopic foreign body 
 removal. Patient ncirnial as to temperature, jjiilse and respiration 1)efore oper- 
 ation. 
 
 acute conditions are present, we may have a severe reaction, though 
 it is very rarely fatal. Lesser degrees of virulence of infective in- 
 flammation present prior to bronchoscopy may produce only moderate 
 reaction as shown in Fig. ITl, whicli is quite typical. Out of 'M cases 
 of children in which the larvnx and trachea seemed to be jierfectly nor- 
 mal, bin in which a loreign bodv was found in the l)r()ncbi, there 
 was no reaction in any instance. Thi' leni])erature did not rise to lOO
 
 260 
 
 FOREIGN BODIES IN LARYNX AND TRACHEA. 
 
 in any but one case and the children seemed normal in every way as 
 to breathing, appetite, and general condition. In one instance there 
 
 w U W U) o * ^ *.o 
 
 Fig. 174. Chart after lironchoscopic foreign body removal in a case in which 
 there existed previously a moderately virulent infective tracheobronchitis. 
 
 was a rise in temperature to 10;!. .\s there was in this instance no 
 cough, no hoarsenes, marked respiratory rise nor other sign pointing to 
 the air passages, but on the other hand gastro-intestinal disturbances,
 
 FOREICX BODIES IN LAKVNX AND TRACIIUA. 2(51 
 
 which were promptly relieved, followed by [irompt subsidence of the tem- 
 perature elevation, Ur. I'rice concluded that the condition was one of gas- 
 tro-enteric trouble and not a reaction from bronchoscopy. On the other 
 hand, in another group of 2() cases, which, on first examination, were 
 seen to have an intense laryngitis or tracheo-bronchitis, either from 
 previous attempts at removal or from the foreign body being thrown 
 about the interior of the air passages, there was a prompt reaction fol- 
 lowing the bronchoscopy with a rise of from one to two degrees in the 
 already elevated temperature. This rise and the reaction was most se- 
 vere in the cases associated with copious pus formation. In three of 
 these cases a peanut kernel was the offending substance, and this par- 
 ticular foreign body seems to have a peculiarly irritating effect upon the 
 mucosa of the lower air passages. From the foregoing statistics, as well 
 as from the general recollections of clinical observations, the author 
 feels justified in the following conclusions: 
 
 1. Bronchoscopy carefully done in children, without an anesthetic, 
 general or local, is unassociated with any reaction worthy of consid- 
 eration, provided the child beforehand is normal as to temperature, pulse, 
 respiration and nearly so as to the local conditions in the laryn.x. trachea 
 and bronchi, and provided the technic is strictly aseptic. 
 
 2. General systemic reaction including temperature elevation, ad- 
 vance in pulse rate and respiratory frequency may be anticiijatcd in any 
 case where the temperature is already above 100, and especially in such 
 cases as have a severe local inflammatory condition in the larynx, trachea 
 or bronchi. 
 
 3. The most severe reactions are due to absorption through abra- 
 sions of the epithelium. These abrasions, when occurring from the for- 
 eign body, cannot, of course, be avoided, but abrasions in bronchoscopy, 
 except in exceedingly complicated removals, need not occur if great 
 care be taken, not only in the performance of bronchoscopy, but also 
 beforehand, to see that all of the instruments are free from roughness 
 and sharp corners or angles. \'on Schrotter (Bib. 50.5) reports a rise 
 of pulse to HO with rapid, irregular heart action but without dyspnea, 
 due to the patient having swallowed a considerable amount of air during 
 bronchoscopy, causing a dilatation of the stomach. The symptoms all 
 subsided after a rest in bed. 
 
 Shock. To the writer's knowledge no accurate experimental work 
 has been done in regard to the degree of shock, if any, in bronchoscopy 
 and esophagoscopy. Taking Crile's definition of surgical shock as a 
 "low blood pressure." the author has never seen a single instance in any 
 way approaching surgical shock, in a case where tliere had been no 
 operati\c measures other lli;in the endoscopy. .A number of cases have
 
 2f>2 FORF.rGN BOniES IN LARYNX AND TRACHKA. 
 
 had severe fatigue ; especially noted in children after a prolonged bron- 
 choscop\'. When the author first noted the interesting observations of 
 Yandell Henderson on the acapneal hypothesis of shock, the author was 
 surprised that nothing of the kind had ever been noted after bronchoscopy 
 without anesthesia. Careful observation, however, revealed the fact that 
 respiration far from being excessive is so much interfered with by spasm, 
 cough, and holding the breath that it seems certain that there is a hypop- 
 nea instead of a hyperpnea. This observation is not intended as applying 
 in one way or the other to the theories as to the nature of surgical shock. 
 They merely go to show that unless unduly prolonged there is nothing 
 approaching surgical shock from a carefully done bronchoscopy or esoph- 
 agoscopy when no traiuna is inflicted. There may be, and doubtless is 
 in many cases, a drug shock. Sargnon reports a case where a tuber- 
 culous pulmonary hemorrhage supervened preventing the bronchoscopic 
 extraction of a pea, the patient dying twelve hours later. Pulmonary 
 tuberculosis cannot be regarded as a contraindication to the removal of 
 a foreign body and it w'as perfectly right and proper in this case to make 
 the attempt. Undoubtedly the hemorrhage would have supervened any- 
 way in a very short time so that such a case can hardly be regarded as 
 strictly a death from bronchoscopy. Mosher reports central hemiplegia 
 during bronchoscopy imder ether. 
 
 Local reaction. Ordinarily the only local reaction noted is a slight 
 laryngeal congestion producing slight hoarseness which disappears in a 
 few days. If dyspnea, without pneumonia, supervene it is usually due 
 to one of three things : 
 
 1. Drowning of the patient in his own secretions. 
 
 2. Laryngeal edema. 
 •5. Subglottic edema. 
 
 Impending drowning of the patient in his own secretions is a com- 
 plication seen by the author in a number of cases. The subject has so 
 many imjjortant bearings that it is separately considered under "Diseases 
 of the Trachea and Bronchi."' Suffice it here to say that it is the first 
 thing to be thought of in dyspneic cases and is (|uicklv relievable by the 
 "sponge ])uniping" jjrocess. In a number of instances, the child has be- 
 come dyspneic within 24 or ;!(! hours after the bronchoscopy, but on 
 passing the bronchoscope, a large quantity of secretion was removed with 
 complete re-establishment of quiet respiration and the disappearance of 
 the dyspnea. It is especially to be anticipated in cases of peanut kernels 
 and other secretion-producing foreign bodies. 
 
 Edema of the supraglottic larynx sufficient to become obstructive is 
 quite rare. The only case of the kind that re(|uired tracheotomy, in the 
 author's experience, was in an elderly ]jatient with advanced nephritis
 
 rORKIGX BODIES IN LARYNX AND TRACHKA. 263 
 
 Subglottic edem-a. The causes of this complication in the author's 
 opinion are : 
 
 1. The use of over-sized tubes. 
 
 2. Undue violence in insertion of the bronchoscope. 
 
 •■^. Faulty position of the patient, the long axis of the trachea not 
 being in line with the bronchoscope as the latter enters the trachea. 
 
 4. Faulty position of the patient after the bronchoscope is intro- 
 duced resulting in undue pressure by making the larynx the fulcrum of the 
 bronchoscopic lever instead of the upper thoracic aperture. 
 
 .J. Trauma by extraction of the foreign body wrongly placed with 
 reference to the long diameter of the glottis. 
 
 Ci. Trauma in the application of local anesthetics through the glot- 
 tis before the bronchoscope is introduced. 
 
 7. The anatomic ami physiologic nature of the subglottic tissue is a 
 contributing cause. 
 
 8. Infective trauma li\- llie foreign l)ody itself prior to the bron- 
 choscopy is uniloulitedly a coiUriluiting factor. 
 
 \'on Eicken has re])orted a number of cases in which a subglottic 
 edema i)resent before bronchosco])y increased after bronchoscopy so as 
 to require tracheotomy. Logan Turm-r has scientifically determined that 
 the development of inflammatory edema of the larynx is dependent upon 
 three factors. 1. Tiie intensity of the inllammatory process producing 
 it. 2. The site of the infection. .'!. The anatomic arrangement of the 
 loose suljmucous cellular tissue of the larynx. The bearings of these 
 observations upon subglottic edema after the sojourn of a foreign body 
 in the subglottic region, or in the trachea where it is intermittently 
 coughed upward toward the glottic chink and aspirated backward again, 
 is self evident, but it is hoped that still further study by this eminent au- 
 thority will llivdw further light upon the occurrence of subglottic edema 
 without general laryngeal edema, after bronchoscopy, as reported by a 
 number of authors. 
 
 The author may be biased but he believes that the ]M-oduction of 
 subglottic edema is lessened by distal illumination by permitting the use 
 of very small tubes and by doing away with the heavy handle, thus per- 
 mitting of the utmost delicacy, and. most important, the thick strong 
 hcavv laryngosco]iic tube is not introdnced through the larynx. The 
 thinnest lin'inings bronchoscoi)e at the laryngeal part of the tube during 
 bronchoscopy is ■; mm. and this Ilriinings states "Cannot be used until 
 the child is from I to ."i nv mills old." Conse(|uentlv in \ery young infants 
 traciieotomy has to be resorted to because as llnniings states: "No re- 
 liance can be jiiaced on the employment of tubes narrower than 7 milli- 
 metres." Tills can only apply to proximally lighted tubes which re(|uire
 
 2(34 FOREIGN BODIES IN LARYNX AND TRACHEA. 
 
 not only a relatively large lumen for illuminating purposes but require a 
 relatively thick and heavy laryngoscopic tube outside the bronchoscopic 
 tube, because by this system the laryngoscopic tube itself is pushed 
 through the glottis. By the author's method the bronchoscopic tube is 
 too thin and light to be used to produce the displacement necessary to 
 expose the glottis, and with distal illumination, a -i mm. tube is quite 
 practical for anyone who will practice with it a while. The author has 
 done a number of peroral bronchoscopies for diagnosis in suspected thy- 
 mic pressure cases in new-born infants without any ill effects from the 
 use of the 4 mm. distally illuminated tube. In the author's clinic, both 
 Dr. Ellen J. Patterson and the author use tubes of 4 mm. and 5 mm. in- 
 ternal diameter, for children under 6 years of age, the 4 mm. tube being 
 for infants under one year. Our youngest patient from whom a foreign 
 body was removed was an infant of 2^/^ months. This was a common 
 pin removed from the right bronchus with a tube 4 mm. internal diameter. 
 Since 1911, not one case of subglottic edema has occurred in the practice 
 of either Dr. Ellen J. Patterson or the author in 3(5 successful removals 
 of foreign bodies in the trachea and bronchi of infants under one year. 
 Every case was done by oral bronchoscopy. This freedom from sub- 
 glottic edema, we believe, is due to the use of small tubes, close atten- 
 tion to the details of introduction and manipulation herein given ; and, 
 especially to the aid of good assistants — in other words to "'team work." 
 Stanton A. Friedberg in a recent case reports the use of a distally illum- 
 inated •") mm. tube in an infant of 3 months, for the peroral bronchoscopic 
 removal of a safety-pin from the right bronchus. Considering the nature 
 of the foreign body this is one of the most remarkable cases recorded, 
 and is the youngest patient from whom a safety-pin has been removed. 
 Dr. Friedberg states, "What pleases me most is the facility with which 
 an upper bronchoscopy was performed on such a young child." Killian, 
 himself, recently has recognized the disadvantage in children of adding 
 the bulk of the heavy laryngoscopic tube to the bronchoscopic tube in the 
 larynx and has devised an excellent set of very small single tubes for 
 children, (Fig. 173), to obviate the bulk of the double tube. These tubes 
 Killian inserts with a mandrin and illuminates with a Kirstein headlight; 
 though the tubes are also arranged to fit the Briinings or Kahler hand- 
 lamp. Faulty direction of the tube on introducing may easily cause 
 trauma by gouging into the subglottic wall, if the axis of the broncho- 
 scope and that of the trachea do not coincide at the moment the tube 
 passes the glottis. In ten different publications within the last two vears, 
 the operators stated they placed the patient in the Rose position. If the 
 patient actually was in the Rose position, he was just exactly rightly 
 placed for the bronchoscope to gouge into the subglottic wall and to risk
 
 FOREIGN BODIES IN LARYNX AND TRACHEA. 
 
 2G5 
 
 a production of subglottic edema, especially if the head of the patient was 
 a little more to one side than the other. Mention is made in the chai>- 
 ter on introduction of the bronchoscope, of the necessity for, and method 
 of, avoiding the use of the larynx as a fulcrum and the bronchoscope as a 
 lever, because not only is the bronchoscopic freedom of movement thus 
 hampered but the incidental trauma is a fruitful source of subglottic 
 edema. The operator, who expects by means of heavy handles, and spe- 
 cial leverage to get along with an illy trained assistant by dragging his 
 patient around with his instrument until he can find the lumen he seeks, 
 will have fre(juent subglottic edemas : and if he cannot improve the tech- 
 nic he had better do a tracheotomic bronchoscopy in order to leave the 
 larynx out of harm's way. P.ronchoscopy should be a gentle art. 
 
 Treatment. When subglottic edema is present, the patient should be 
 closely watched and secretions should be ])romi)tly removed, though if it 
 is certain that the trouble is due solelv to the subglottic swelling, it would 
 
 Fii,. 175. Killian's new tubes for children. What resemble.s an inner tube is 
 really a mandrin for insertion, to obviate the use of the bulky double tube. They 
 will lit the Briinings or Kahlcr handlani]) ; Init Killian uses the Kirstcin headlight. 
 Six sizes are required. 
 
 4.5 mm. lor children 54 to 57 cm. body length. 
 
 5. mm. " " ;8 to 64 cm. " " 
 5.5 mm. " " (15 to 70 cm, " 
 
 6. mm. " " 71 to 85 cm. " 
 
 6.5 mm. " " 86 to 100 cm. " " 
 
 7. mm. " " loi to 120 cm. " " 
 
 perhaps be better not to pass the brcjnchoscope for the removal of se- 
 cretions, but to proceed to a .tracheotomy. Intubation should never be 
 used, as it is not safe in these cases and is very likely to lead to an after 
 stenosis. The same ma\' be said (jf a verv high tracheotomy in which the 
 reaction around the cannula may result in a stenosis from perichondritis 
 or cicatricial contraction which will re(|uire a long period of treatment for 
 cure. When done for subglottic edema, the tracheotomy should be below 
 the second ring of the trachea. 
 
 The patient should be decaniuilated in a few days. Should the edema 
 become chronic and prevent decannulation, direct galvano-cauterization as 
 elsewhere herein explained, .should be done. The treatment of other 
 complications arc within the province of the internist and pediatrist.
 
 CHAPTER XIV. 
 
 Removal of Foreign Bodies from the Larynx. 
 
 Syiii[<tonis and diagnosis. The older laryngologic works contain 
 lengthy descriptions of signs and symptoms by which the presence of a 
 foreign body in the larynx was to be differentiated from neoplasm and 
 other diseases, particularly laryngitis, diphtheria, and spasmodic croup. 
 This was necessar\ because of the difficulties attending mirror laryngo- 
 scopy in children. To-day the promptness and certainty of diagnosis by 
 the direct method of examination has rendered all this unnecessary. In 
 the earlier days the usefulness was limited because it was thought that 
 anesthesia was necessary ; but as the author has abundantly proven, no 
 anesthetic, general or local, is necessary for a diagnostic direct laryngos- 
 copy in any infant or older child. The prompt, safe and successful re- 
 moval of foreign bodies from the larynx is one of the greatest achieve- 
 ments of direct laryngoscopy. Xot only is it exceedingly difficult to see the 
 larynx of a child, but even if seen, removal by the indirect method is of 
 such extreme difficulty that tracheotomy has usually been done in days 
 jiast in preference to attempting indirect removal without general anes- 
 thesia, and of course general anesthesia is absolutely contraindicated be- 
 cause of the laryngeal obstruction. ( )n the other band by the direct method 
 foreign bodies can be removed from the larynx of children without any 
 anesthetic, general or local and without tracheotomy, .\nother great ad- 
 vantage of the direct method is that in case of impacted foreign bodies 
 which have to be rotated for safe remoxal. the rotation is easily accom- 
 plished by means of the straight instruments. This was impossible with 
 the angular instruments rei|uired by the indirect method. Such a case is 
 shown schematically in Fig. 17(i. which illustrates the difticulties presented 
 by the firm lodgement of a safety-pin in the edematous larynx of an in- 
 fant of 8 months. Notwithstanding the achievements of the direct 
 method it is still quite common to have children with foreign bodies in 
 the larynx given antitoxin on an erroneous diagnosis of laryngeal diph-
 
 RKMOVAL OF FORKIGX BOPIF.S I'ROM THE LARYNX. 267 
 
 theria. Of course, if for any reason a direct laryngoscopy is not to be 
 had promjjtly because of lack of instruments or of familiarity with their 
 use, it is perfectly right to give antitoxin rather than delay 21 hours for 
 a diagnosis, liul when the da)- shall have arrived that every laryngolog- 
 ist and every pediatrist will be able to examine the laryn.x of any child 
 without any anesthetic, general or local, the necessity for "a shot in the 
 dark" will cease to exist. Harmon Smith (Bib. 'i09 ) reports a very in- 
 teresting case (if a closed safety-pin. The patient had not only been 
 gi\en antitoxin for diphtheria, but had been intubated. The intubation 
 tube was coughed out, leav'ing the pin in situ. Harmon Smith discovered 
 and removed the pin by direct laryngoscopy, and very justly urges that, 
 in all cases in wliich cultures are negative and no membrane is in evi- 
 dence, the larynx and the trachea should be examined bv the direct 
 method "if for mi other reason than to exclude the presence of a for- 
 eign body." .\lmost every endoscopist has had a similar experience. 
 When we add to such occurrences the great number of papillrjma cases 
 the neglect of direct laryngoscopy begins to assume the aspect of serious 
 lack of efficiency. Jn one case reported repeated operations for papil- 
 loma had been pi-eviously done, the fungations having been mistaken for 
 neoplasms. 
 
 Many cases of foreign body in the larynx are immediately fatal 
 as the columns of the newspapers show. Many others are extremely 
 dyspneic when they come to the laryngologist. Xo physician or sur- 
 geon should iiesitate to do an immediate tracheotomy in such cases. In 
 lesser degrees of dyspnea the child must be carefuU)- watchetl until pre- 
 parations for direct laryngoscopy- can be made, because of the risk of a 
 sudden increase of dyspnea from a shift of the foreign body, drowning 
 of tlie patient in his own secretions, spasm, edema, etc. 1 'reparations 
 for a tracheotomy should also be made, not that the direct laryngoscopy, 
 if carefully done, would ordinarily provoke stenosis, but the foreign 
 body might be siiifled. It is well to remember that these cases often 
 come in exliausted because for days and nights they have been too busy 
 fighting for air to either eat or sleep. It re(|uires but little to cause them 
 to give up the fight because of exhaustion. For this reason also it is 
 never wise to prolong the examination. They cannot stand for long the 
 spasmodic reflex closure of the glottis. 
 
 Preliminary c.vamiiiatian. .As previously stated, in every case of 
 foreign body, regardless of whether it is expected to be in the larynx, 
 trachea, bronchi (jr esophagus, indirect mirror examinations should be 
 made, if the patient be old enough. The patient should be recumbent. 
 In a number of cases where a foreigi-i 1)0(1\- was susjiected by the patient. 
 a local lesion has been found ; in three instances tuberculosis had pro-
 
 268 REMOVAL OF FOREIGN BODIES FROM THE LARYNX. 
 
 duced no symi)toms until the patient strangled on some article of food 
 which was thought to have entered the larynx. On the other hand, es- 
 pecially if granulations are present, the endoscopist must be on his guard 
 against making a diagnosis of disease from the appearances of inflam- 
 matory changes which may be secondary to the presence of a foreign 
 body. Quite a number of such cases have been reported and the author 
 
 Fig. 1/6. Schema sliowing lodgement of a safety-pin in the larynx of a male 
 infant eight months of age. The pin was pushed downward, rotated and re- 
 moved with its greater plane sagittally. Rotation would have been impossible with 
 the angular instruments necessary in direct methods. 
 
 has seen two cases of foreign body in the larynx that simulated tuber- 
 culous perichondritis. If, however, a foreign body is discovered by the 
 indirect method, the removal should not be attempted by the indirect 
 method unless the operator be one of those experts who by long prac- 
 tice with indirect operating have developed an unusual degree of skill. 
 If an indirect attemi)t is made the patient must be recumbent in the
 
 REMOVAL OF rORKIGN UODIKS FUnM THE LARYNX. 269 
 
 author's position. (Fig. 73a). Quite a large proportion of foreign bodies 
 in the lower air passages have been dislodged and lost downward. 
 
 Tecluiic of direct luryngoscof'ic removal of foreign bodies. Differ- 
 ing from foreign bodies elsewhere the first step is not to study out the 
 mechanical ])roblem. Because of the risk of loss downward, it is best 
 to seize the foreign body as soon as seen and to proceed to study how 
 best to disim])act the intruder. If the larynx contain suspicious gran- 
 ulation tissue it is as well to remove it. as removal will cause no more 
 bleeding than sponging, and in the event of no foreign body being found 
 the examination of the tissue may contribute to the diagnosis. The me- 
 chanical problems of disimpaction are similar to those in the trachea and 
 bronchi and need not be extensively considered here. Because of the 
 chink-like lumen of the glottis and the frequency with which part of a 
 foreign body gets hooked below the lateral glottic borders, rotation is 
 more frequently required for disimpaction. Rotation will also be re- 
 quired for foreign bodies engaged in one ventricle or transfixed with 
 one end in each ventricle. Rotation is best accomplished with the rotation 
 forceps. (Fig. ilO). The problem of the foreign body hooked below the 
 glottis is well illustrated in the schema. Fig. 176. In this case trauma 
 would have resulted from its being brought up through the glottis, so it 
 was rotated so as to bring its greater plane sagitally, permitting easy and 
 harmless withdrawal. Not infrequently a child will come in completely 
 a])honic from a foreign body wedged in the subglottic space and pro- 
 jecting upward between the cords which, in consec|uence, cannot approx- 
 imate. Usuall\- such a position of the foreign body results from cough- 
 ing the intruder up from below. Careful work with the alligator forceps, 
 the ])atient being recumbent, will usually succeed, especially if no anes- 
 thesia is used. 'J'he application of a local anesthetic may mechanically 
 dislodge the intruder, and the relaxation of a general anesthetic may re- 
 lease it. In some cases it will be found that a tracheally lodged foreign 
 body can be easily seen through the glottis and can Ik- removed bv in- 
 serting the alligator forceps during inspiration. This should only be 
 done, however, where there is no great dys])nea. and where the foreign 
 body is small in one diameter and large in the other, allowing plenty of 
 air to pass on each side, and also allowing a ready grip with the forceps 
 inserted so that the jaws will open at right angles to the longest pre- 
 sented diameter. The intruder must be turned so that its longest diam- 
 eter comes sagitally llirough liie glottis. For this, Mosher's forceps are 
 excellent.
 
 CHAPTER XV. 
 
 Mechanical Problems of Bronchoscopic 
 Foreign Body Extraction. 
 
 The greatest triumph of bronchoscopy over thoracotomy is in the 
 low mortaHty of bronchoscopy. Esophagoscopy presents a simihir tri- 
 umph. The problem is not simply to remove the foreign body. A strong 
 forceps and main strength would do that. The problem is the removal 
 without endangering the patient's life. A careful study of the mechanical 
 problems presented will always discover a safe method of removal. In 
 view of this, the temptation to remove the body at all hazards once it is 
 grasped, must be resisted. The endoscopic extraction of a foreign body 
 is a mechanical problem pure and simple. A bad mechanic will either 
 fail to remove the foreign body or will kill the patient or, alas, will do 
 both, as has already happened a number of times, to the undeserved 
 discredit of bronchoscopy and esophagoscopy. Being a mechanical prob- 
 lem it can be best illustrated by reference to every day experience in me- 
 chanics. For instance, a cap-screw is broken ofif flush with the surface 
 of the cylinder of an automobile engine. The repairman who is not a 
 mechanic will ])ound away with a ]ninch in an effort to turn the screw 
 out. He breaks the entire engine casting by hasty, ill-[)lanned or rather 
 unplanned efl^orts at removal. The good, careful mechanic will care- 
 fully cut a slot in the broken screw. This slot will enable him to use a 
 screw-driver, by means of which he will remove the screw without dam- 
 age to the engine, in less time than it took the unmechanical repairman 
 to ruin the entire engine. L'nfortunately, endoscojjic work has been done 
 on the basis that, left in situ, the foreign body would probably be fatal ; 
 consequently, any violence in removal was justifiable. The basis is in- 
 disputable, but the inference is erroneous. In the solution of the me- 
 chanical problems involved, as well as in their execution, the utmost pa- 
 
 *I-ecture given by the author before the New York State Medical Societ.v, Sec- 
 tion on Laryngology, New York City, April 30, 1914. Revised and supplemented.
 
 MECUANirAI. I'KllKI.I-.MSlll- IMKiaCN liODV EXTRACTION. 371 
 
 tience is necessary. The hasty, brilliant man may remove the foreifjn 
 body, but the removal may be fatal to the patient. 
 
 As Briinings has well said, '"The description of operative technic, 
 which affords such an unlimited scope to the person of skill, ingenuity 
 and talent for mechanical adaptability, encounters quite special difficul- 
 ties." 
 
 Only general rules can be laid down ; and the author wishes par- 
 ticularly to warn any one from taking any of the following suggestions as 
 absolute for application to a case which may present itself. Every case 
 must be dealt with upon its own merits, and variations from any rules 
 will naturally suggest themsehes to the mechanically inclined. The au- 
 thor can say this, however, that every statement made herein as to me- 
 chanical problems, unless otherwise stated, is a note made at the time 
 when the particular plan had resulted in a successful issue. Fast e.x- 
 perience becomes a guide for future jjrocedures, but it is a guide that 
 must not be followed implicitly without reasoning as to whether or not 
 it is applicable to the particular case in question. It must be remem- 
 bered, also, that there is more than one way of doing things mechanical, 
 though, as applied to foreign body extractions, it will usually be found 
 that one plan is better than another, because of the personal equation of 
 the operator. For instance, nearly every endoscopist has his own i)in 
 closer. The chapter of case rejjorts will contain notes of how the me- 
 chanical problems were dealt with. 
 
 The lip of the bronchoscope and esophagoscope is one of the most 
 important factors in the solution of the mechanical problems of foreign 
 body extraction. Under the manipulation of the well-trained left hand, 
 co-ordinating with the forceps, hook or snare in the right hand, the en- 
 doscoi:ist has a binimuial, eye-guided control that can accomplish what 
 seems wonders to an\()ne whose work has been limited to square-ended 
 tubes and unaided right-handed forceps manipulations. The bimanual 
 control is p()s--iblc (inly because of the li|i of the slanted tube-mouth. 
 This lip is of the greatest aid in making a space at the side of a foreign 
 body where the intruder imjiinges on the bronchial wall, for the inser- 
 tion (if the furceps jaw. It forms a shield or protectnr that can lie 
 slijiiied under the point ot a jiin or other sharp foreign body and can 
 make counter-pressure on the tissue while the fcjrcejis are disembedding 
 the point ot the foreign bixh. In nian\ other wavs it can be used to as- 
 sist once the habit of working with a knowledge of its direction in rela- 
 tion to the hanille is mastered by practice. The lip cannot be seen as 
 such in looking through the tube. One of the most imjiortant ]ioinls in 
 foreign body extraction is to introduce the tube until the distal end ar- 
 rives at the [iroper distance above the foreign body. What constitutes
 
 273 MECHANICAL PROBLEMS Or FOREIGN BODY EXTRACTION. 
 
 the proper distance varies in the different cases. So far as merely see- 
 ing the object is concerned, the tube need, ordinarily, not be very close 
 to the foreign body. But the mechanical problem of removal is closely 
 concerned with the distance of this rigid tube-mouth, and the tube must 
 be "anchored" in the chosen place by the left third and fourth fingers 
 hooked over the upper alveolus (Fig. 137), while the right thumb and 
 first two fingers make lateral pressure to swing the bronchoscope, if need- 
 ed, to displace swollen mucosa, open the lip of a bronchial orifice or the 
 like. Never go into any foreign body case hastily or unprepared with the 
 idea of taking a preliminary obser\ation. Often the first sight of a for- 
 eign body is the best you will ever get. If not immediately removed it 
 may become more difficult later, through being hidden by mucosal swell- 
 ing, dropping into a smaller bronchus, passing down the esophagus, etc. 
 
 The use of iwoks will be mentioned in connection with various me- 
 chanical problems. The Lister hook is very useful. Small probe point- 
 ed hooks are excellent but a right angle is sufficient for most purposes. 
 Hooks with a curve greater than a right angle are very apt to become en- 
 gaged in small orifices and to be very difficult in removal. 
 
 The use of forceps in endoscopic foreign body extraction. The au- 
 thor uses two different strengths of forceps. The regular forceps is so 
 strong and firm that the full amount of strength of an ordinary man's 
 fingers can be applied without bending or breaking the forceps. These 
 are necessary in foreign bodies which present a hard, smooth conical 
 end towards the operator, the strength of instrument being necessary 
 not for traction but to pre\ent the forceps slipping oft" such bodies. These 
 force])s. however, are not so well suited to extremely delicate manipula- 
 tions because they are larger in size. The more delicate forceps are jusi 
 one-half the dimensions of the larger ones and they will suffice for ordin- 
 ar}' extractions, but they must be used with consideration and care, or 
 they may get bent or broken. Or, indeed, the delicate or friable foreign 
 bodies may get bent or broken. As in all other mechanical problems, 
 and practically all of the problems in foreign body extraction are me- 
 chanical, the operator must use judgment and adjust the means to the 
 end. It is absolutely essential, for accurate work, that the forceps be 
 seen to close upon the foreign body. This is one of the chief reasons 
 why the author prefers distal illumination. The illumination of the field 
 is just as good after the forceps are introduced as it was before, and all 
 the operator has to do is to look i)ast the near part of the forceps. The 
 practiced eye will, in every case, see the jaws close under the guidance 
 of the eye. even in the 4 mm. tube, of whose lumen the forceps occupies 
 nearly one-half of the entire diameter. The crevice remaining is suffi- 
 cient because the illumination is uninterfered with. However reliable
 
 MliCHAXICAL I'KOBLHMS OF FOREIGN BODY EXTRACTION. 273 
 
 the sense of touch, there are many thhigs in foreign body extraction in 
 wliich the sense of touch alone will not be a sufficiently accurate guide 
 to safety and success. .Most iniiiortant is development of the ability to 
 gauge depth with one e\e alone. Those who have never tried it think 
 that this is easy, those who have tried it only once, think it is impos- 
 sible. Those who h.nve the natural aptitude to begin with and who de- 
 vote a sufficient length of time to it, can develop this sense to an extent 
 that seems incredible. When one sees a foreign body for which one has 
 been searching there is naturally great eagerness to seize it and remove 
 it. 'i'his impulse must be resisted and a careful study of the size, shape 
 and ]iosition of the foreign body and its relation to surrouncUng struc- 
 tures must be clearly determined before any attempt at extraction is 
 made. To seize it and tear it out regardless of the harm that may he 
 done is to court disaster, for however successful it may be in a possibly 
 considerable number of cases, the endoscopist is bound to encounter 
 other cases in which such a procedure will be fatal, and needlessly fatal. 
 In apiiroaching a foreign body with the forceps, to grasp it, careful 
 watch should be kept by the eye to see that the forceps do not touch 
 the foreign l)(idy licfore the jaws are expanded, as this may have the ef- 
 fect of driving the foreign body more deeply. The forceps are inserted 
 through the bronchosco])e closed and are allowed to expand when they 
 are within a few niillimelers of the intruder. In using forceps, the tube 
 mouth must not be so close to the foreign body as to hinder the expan- 
 sion of the forceps jaws, unless the intruder be small, such as a pin or a 
 needle, in which case ample ex|)ansion can be h.-.d within tlie tube. This 
 is the better way to w^ork in case of pins or needles, because the points 
 can be inore or less fixed by the jiressure of the tube while the forceps 
 are being placed. The first trial of forceps extraction is always the best 
 ojiportunity for reinoval. because of secretions, possibly blood stained, 
 set free as soon as the foreign body is disturbed. Therefore, the proper 
 placing of the forceiis on the prii|K.-r part of the foreign body to insure 
 its extraction, should be plaimed before the forceps are inserted. As ex- 
 plained under eso|)hagoscopy, the point at which the foreign body is seen 
 makes a great difference with certain foreign bodies which should be 
 allowed to turn in order to present their least diameter to the cross sec- 
 tion of the bronchus ; and also, in certain cases, to turn where a point or 
 rough place on the foreign body will do no hann. h"or permitting rota- 
 tion, it is necessary to use forceps such as the author's "rotation" for- 
 ceps, Fig. 3:i, in order that the foreign body may be free to turn. For 
 use with llie lar\iigoscoi)e or esophageal speculum the author's alligator 
 rotation forceps are used. (Fig. :ilO.)
 
 2"-i MECHANICAL PROBLEMS 01' FOREIGN BODY EXTRACTION. 
 
 When the forceps have slipped off a foreign body during attempted 
 extraction, the bronchoscope has usually been slightly withdrawn. At 
 this point extreme caution is necessary. The first thing to remember is 
 never to push the bronchoscope immediately downward again. On the 
 contrary, it should be withdrawn a centimeter or two. Then the secre- 
 tions and blood, if any, should be carefully sponged away and a good 
 clear view of the tracheal or bronchial lumen obtained. Then, being 
 sure the foreign body is not being overridden, the bronchoscope is slow- 
 ly advanced and each step of the way is searched until the old location is 
 reached. If the bronchoscopist were hastily to push the bronchoscope down 
 to the place where the foreign body was previously seized, the foreign 
 body might easily be overridden, its point, if any, caused to puncture or 
 to enter a lateral branch, or it might be lost in the secretions requiring 
 prolonged search. Precipitate grabbing with the forceps never accom- 
 plishes anything and may do serious and even fatal damage. It is well 
 to see that the thumb nut of the forceps is in place, and to look carefully 
 to the angle of closure of the forceps, to make sure that they grip prop- 
 erly. The proper closure is illustrated in Fig. ol. 
 
 Lateral movements of the forceps by the author's method. In mak- 
 ing lateral movements of forceps, the tube mouth, either the lip or the 
 short side, is used, as required. The bronchoscope is swung in the re- 
 quired direction as a lever on its fulcrum (Fig. 13.5) carrying the distal 
 end of the forceps strongly sidewise. This maneuver, devised by the 
 author, has been exceedingly successful, and has led him to wonder at 
 the statements made that lateral movements of forceps are impossible. 
 In combination with the side curved forceps (Fig. 2!') some otherwise 
 difficult maneuvers become easy. 
 
 Briughig the foreign body throiu/h tlie glottis. Stripping of the for- 
 eign body from the forceps at the glottis in cases where tube, foreign 
 body and forceps are withdrawn together, is so frequently reported that 
 it deserves special consideration. This accident is due to one of four 
 causes : 
 
 1. The foreign body was not being brought out with its largest 
 diameter in the sagittal plane of the glottic chink. 
 
 2. The forceps w-ere not most advantageously applied. 
 '■'. The forceps were mechanically imperfect. 
 
 4. The foreign body was not kept close up to the tube mouth, thus 
 allowing the glottic tissues to close tightly on the forceps between the 
 tube mouth and the intruder. 
 
 The remedies are obvious in each class of case, except in class 2. 
 To make sure of proper grasp accurate closure of the forceps under 
 ocular control is the greatest safeguard. In a<l<Iiti()n, however, it is well
 
 MKCUAMCAl, rKOIM.KWS OF I'OUIirCN BODY KXTRACTlON. 37.') 
 
 to test the firmness of grasji of the forceps against the end of the tube 
 before starting to withdraw forceps, tube and foreign body all together, 
 because if the grasp is insufficient, it is better to know it before with- 
 drawal is attempted than to have the intruder become wedged in the 
 glottis, or to lose it back in the trachea. In the case of small objects, if 
 scraped oiif by the glottis, they may drop back into a new location where 
 removal and finding may be still more difficult. For these reasons, it is 
 best to assure one's self that the grasp is firm before the foreign body is 
 removed from the locality in which it is found. As a rule, it is unsafe 
 to attempt to test the grip of \ery soft friable bodies by withdrawing 
 them against the end of the tube, except with the utmost gentleness, be- 
 cause of the likelihood of crusiiing. When a foreign body is strijiped ofif 
 the forceps on withdrawal it ma\ Ijecome jammed in the glottis in such 
 a way as to occlude breathing comjiletely. It is therefore wise to have 
 always at hand the alligator jawed forcejjs which can be used promptly 
 through the direct laryngoscope. In the event of the foreign body not 
 being of such shape as to occlude the glottis this method of removal will 
 be the most convenient anyway and as jiointed out by D. R. I'aterson, 
 the circumstance may be e\en furtunate in pre\enting the loss of the 
 foreign body downward. Nevertheless, it will require prompt action in 
 some cases to avert disaster. The accident of stripping oft the foreign 
 body at the glottis often makes the situation much more complicated by 
 the large quantity of pus and secretions that are liberated bv the loosen- 
 ing of the foreign body, which had been occluding the bronchus. In such 
 case, a careful removal of the secretion by "sponge pumping" as men- 
 tioned under ".Xsijirators" is necessary. Then careful search is resumed. 
 Usually the foreign body will be found not to have gone so deeply. If 
 large, it may stop at the bifurcation, c\cn though it had previously been 
 nuuli lower. .Most foreign bodies require time to work their wav down- 
 ward. Care must be used not to override the intruder as explained in 
 connection with "Use of the forceps." The accident of dropping from 
 the grasp of the forcc])s during process of broncboscopic removal seems 
 from the literature to have iieen (|uite a fre(|uent accident and in some 
 instances it has ])roven fatal. < )ften the foreign body will be found to 
 ha\e dropped into the o]i])osile bronchus from tiiat in wlncli it was first 
 lodged, the reason iieing probably, that the negati\e |)ressnre is very much 
 less in the bronchus of the first itnaded lung because secretions have ac- 
 runuilated and in cases of long standing there may be obliteration of a 
 large amount (jf lung tissue, whereas the negative pressure is increased 
 by the compensatory activity of the sound side. To prevent this drop- 
 ]iing into the main ijronclnis of the opposite side, r.ninings has suggestCkl 
 the use of .'i "broiu'hus |)rotector" which is like a bottle briislt. It is in-
 
 376 MECHANICAL PROBLEJIS OF FOREIGN' BODY EXTRACTION. 
 
 serted into the sound bronchus before attempting the removal of the for- 
 eign body from tlie invaded bronchus. Its brush-like form permits of 
 respiration but will prevent the entrance of a foreign body of any 
 appreciable size. Hinsberg reports an interesting case in which 
 a plum stone in process of removal from the right bronchus 
 slipped from the forceps and dropped into the left bronchus from which 
 he could not remo\e it. The patient died within a few hours. It 
 was found at autopsv that the right lung was atrophied, the patient hav- 
 ing existed almost solely on the left lung, the use of which was suddenly 
 lost when it was occluded by the falling backward of the foreign body. 
 Ingals (Bib. 22^) reports two cases in which the foreign body in process 
 of bronchoscopic removal slipped from the forceps and prolonged search 
 in the trachea and bronchi failed to find it. The search was given up 
 and the bronchoscope withdrawn. In one of the cases after withdrawal 
 the foreign body was found in the patient's mouth and in the other case 
 it fell out on the floor. This points a very valuable lesson that should al- 
 ways be borne in mind. After a foreign body has slipped from the for- 
 ceps seemingly at the glottis, on withdrawal of the bronchoscope, forceps 
 and foreign body all together, it must be remembered that there is a pos- 
 sibility that it really came through the glottis and m;u' be in the pharynx 
 or perhaps swallowed. This, however, must not prevent us from ])rompt 
 reinsertion of the bronchoscope especially with foreign bodies which may 
 cause dyspnea, but if a preliminary search fails to find the foreign body 
 in the trachea or bronchi very careful search of the pharynx should be 
 made with the finger and if the bronchoscopy has already lasted a con- 
 siderable time it is better to desist and have another radiograph taken 
 because the foreign body may have been swallowed. 
 
 Extraction of pins, needles and similar long pointed objects. In case 
 of such bodies as pins, tacks, nails and the like, whose points are pre- 
 senting and thus the mechanical problem clearly apparent, we may pro- 
 ceed at once to raise the point with the lip of the bronchoscope so as to 
 get the point into the lumen. It is usually better that the forceps be not 
 used to seize the point until the point is in the lumen, as otherwise the in- 
 truder will almost certainly get crosswise of the tube mouth. For the 
 same reason a pin, needle or similar object must be first studied from a 
 distance lest the tube mouth override the proximal end of the [lin. In 
 other words the nearest end must be searched for first, and the rule 
 should be to look, not for a pin, but for the point of a pin. One pull 
 with the forceps on the middle portion of a ])in has caused the point to 
 [perforate, enormously increasing the difficulties of removal and in some 
 instances resulting fatally. (Fig. 177.) Even if grasped near the point, 
 if the grasp is exactly "on end" there is a strong tendency for the point
 
 MKCHAXICAI, rUORLI'MS OF FOREIGN BODY EXTRACTION. 
 
 277 
 
 of a pin to hook over the mitsiilc uf the tube mouth. In such a case, as 
 soon as the forceps gras]) the pin, the pin should be pushed downwarti, if 
 necessary to free its point, or if this is unnecessary, the tube can be 
 
 slightly withdrawn so that the i)oint will not become hookec 
 
 :r the 
 
 edge of the tube in witiidrawal. To still further prevent this hooking 
 over the edge, it is often necessary to move the lip of the tube mouth 
 rather strongly in the direction of the point. The author usuall)' |)rcfers 
 the pushing downward of the pin with the forceps to disengage it, when 
 safely possible ; but it may be disengaged by putting a hook below the 
 place where the point disappears into the mucosa and by withdrawal up- 
 ward the point can be forced out. (Fig. ITS.) This, of course, is not 
 
 M 
 
 
 
 
 
 s 
 
 Fig. 177. .Schema illustrating one phase of the error of graspin.i; a long for- 
 eign body in the middle, upon first seeing it across the tube mouth as at M. It 
 gets crosswise of the tube mouth, like a "toggle and ring," and the point cannot 
 be drawn into tnl)c moiilh for protection. 
 
 I)erniissible if the jKiint is deeplv embedded. For the grasping and with- 
 drawal of pins the side-curved forceps (Fig. 2')) are admirably adapted. 
 The side curve enabling a grasp sidewise when the pin is lying in contact 
 with one bronchial wall as it usually is. They can also be used closed as 
 a hook. I'ins, esjjecially the glass-headed steel pins in common use, are 
 very prone to droj) down into the smaller bronchi and to disappear com- 
 pletely from the ordinary field of endosco]:)ic ex]5loralion. Pins with 
 slightly larger iieads not dropping so deeply, and yet gi'ing into the 
 branches of the stem bronchus, are verv prone to appear and disajipear 
 during endoscojiy, in a way that makes them, at times, quite difficult to 
 tind and remove. Cough will throw the point into view, but the point will 
 iniiut'(li;itely recede before it c;ui be gras])e(l by the forceps. This a])-
 
 278 
 
 MECHANICAL PROBLK MS ClF FdRHlCN BODY EXTRACTION. 
 
 pearance and recession are due to the elasticity of the bronchi, the up and 
 down movement during respiration, and is seen at its greatest degree 
 during cough. When the intruder is found the depth of the insertion of 
 the bronchosco[je must be maintained by sufficient pressure with the 
 thumb and finger to prevent its being displaced by cough. The axis of 
 the foreign body having been tletermined, the forceps are inserted in such 
 position that the jaws will open in the proper plane for grasping. In one 
 of the author's cases an assistant pushing upward under the ribs raised 
 
 Wi> 
 
 ^J^ 
 
 Fig. 178. Illustrating the mechanical problem of the pin, needle (P), tack or 
 nail with imbedded point (M), and its solution. If the forceps, H, is pulled up- 
 on, the head, P, beinj; in a bronchus, cannot swing round, and the point, M, of the 
 pin is buried still deeper, enormously increasing the difficulties of removal or 
 causing fatal trauma. If instead of pulling upon the forceps, H, they are I'lishcd 
 as shown by the dart, the point may be disengaged, and the lip of the broncho- 
 scope may be slipped under the disengaged point. If the pin is prevented by its 
 head from being pushed downward, the point may be extracted by traction with a 
 hook as shown at B and C. The forceps, Fig. 33, may be used instead of the 
 hook for freeing the point. In either case the extraction is then done with the 
 forceps, Fig. 28, or preferably, 29. (See Fig. 179a.) 
 
 the lung tissue against the tube mouth enough to cause the point of a 
 pin "around the corner" to emerge. ( Fig. 172.) In two cases the rise of 
 the diaphragm in connection with cough expulsion forced the lung up- 
 ward by diaphraginatic compression sufiiciently to cause the pin point to 
 emerge, rather firm cotmterpressnre being maintained with the broncho- 
 scope on the tissues. Tlie forceps were introduced and the next emer- 
 gence was waited for when the point was instantly seized and the pin 
 withdrawn through the bronchoscope in both cases. In one instance, the 
 author had a verv interesting case in which a pin became transfixed across
 
 MECIIAXICAL PROBLEMS OF FOREIGN BODY EXTRACTION. 
 
 279 
 
 tlic lumen of the bronchoscope through the breathhig aiJcrtures and into 
 the opposite wall, recjuiring breaking of the pin by pushing on the forceps. 
 The relative position of the apertures has since been changed to prevent 
 such a possibility. Ingals has devised a very ingenious corkscrew-like 
 instrument which will bring a pin into the corner of the lumen in cases 
 where a point is deeply Iniried. 
 
 In the bronchi, it may not be possible to push the foreign body suf- 
 ficiently far down to disengage the point. Under such circumstances, if 
 the point cannot be liberated by the methods already mentioned, the pin 
 must be cut or broken. Casselberry has devised a very ingenious forceps 
 
 
 
 Fig. 179. Schema illustrating a serious phase of the error of hastily seizing a 
 transfixed pin near its middle, when first seen as at M. Traction with the forceps 
 in the direction of the dart in schema B will rip open the esophagus or lironchus 
 mflicting fatal trauma, and probably the pin will be stripped off at the glottic or 
 the cricopharyngeal level, respectively. The point of the pin must be disembedded 
 and Kottcn into the tube mouth as at A, to make forceps traction safe. 
 
 t(ir the |)urp()se of ciUling pins, and at the same time retaining the point, 
 lie fore using, these forceps should be tested upon a pin to make sure that, 
 after cutting the point can be held in the forceps and not get lost. In 
 use the forceps must be held closed after closing in order not to drop the 
 pin in three pieces, \ankauer has devised a method of dealing with the 
 crosswise fixed pin by pulling it into the tube of a combination tube antl 
 hook forceps, which seems a promising though as yet untested method. 
 It is intended for untempered ])ins which will bend without breaking. 
 He has successfully used an instrument shaped like a tack-drawer for ex- 
 tracting the embedded point of a tack ; and this should be equally useful 
 for an embedded pin poiiU.
 
 280 
 
 MECHANICAI, PROBLEMS OF FOREIGN BODY EXTRACTION. 
 
 Extraction of lacks, nails and large licadcd foreign bodies from the 
 tracheobronchial tree. Tacks with sharp points often present the prob- 
 lem of the buried point and the "toggle and ring" tendency to hook over 
 the tube mouth if not grasped on end, which have been considered in the 
 section on extraction of pins. In addition, however, the large head pre- 
 sents a special problem because of its tendency to act as an anchor when 
 buried in swollen mucosa, or in a cicatricial stenosis. The latter con- 
 dition will be mentioned in a future chaiiter on the problems associated 
 
 Fig. 179a. Schema illustrating the mechanical prol)lem of extracting a pin, a 
 large part of whose shaft is Iiuried in the hroncliial wall, B. The pin must be 
 pushed downward and if the oritice of the branches, C, D, are too small to admit 
 llie head of the pin some other orifice (as at A) must be found by palpation (not 
 ijy violent pushing) to admit the head, so that the pin can be pushed downward 
 permitting the point to emerge (E). The point is then manipulated into the bron- 
 choscopic tube-mouth by means of co-ordinated movements of the lironchoscopic 
 lip and the side-curved forceps, as shown at F. 
 
 with prolonged sojourn. The traction renuired in some instances raises 
 the question as to how much traction one may safely make. The tracheo- 
 bronchial tree, and with it the lungs, are so freely movable that it can be 
 felt to yield resiliently when traction is made on an "anchored" tack.* In 
 many such cases, however, it will be found that the foreign body is not 
 properly grasped and that traction is being made more or less at an angle, 
 which causes the foreign body to get more or less of a hook-hold on the 
 
 •strong and ill-directed traction has ruptured the bronchu.s and proven fatal 
 in a number of patients sent in to the author in a dying condition from mediastinal 
 emphysema or pneumothorax, the tack not being removed (Fig. 179a). In other 
 case.<! extraction had been rendered infinitely more difficult for the avithor b.v the 
 mutilation caused by the injudiciou.s traction. Swollen muco.sa around the head 
 of the tack may cause some resistance to traction.
 
 MECHAXICAI, PROr.I.EMS OF FORKTGX BODY EXTRACTION. 
 
 381 
 
 angle projecting at the hraiK-li bronchus. This is especially true of bodies 
 like the upholsterer's tack, of which every bronchoscopist of experience 
 has had one or more cases. These tacks hold like a "'mushroom anchor," 
 and great care must be taken that traction is being made in the proper di- 
 rection. The direction of traction can be modified by the position in which 
 the forceps are placed, as previously described ; and it can also be modified 
 by the movement of the head of the patient and the bronchoscope in the 
 proper direction. The lip of the bronchoscope can also be used for the 
 moving out of the way of the obstructing tissues, as elsewhere described, 
 and as illustrated in Fig. IT"^. The shortness of a tack may per- 
 mit it to turn more or less sideways in the bronchus, the ]X)int entering 
 
 Fig. i-g1>. "Musliroimi anchor" prolilcni of the upholstery tack. If the tack has 
 not been in situ more than a few weeks the stenosis at the level of the darts is 
 simply edematous mucosa and the tack can be pulled through with no more than 
 slight mucosal trauma, provided axis-traction only be used. If the tack has been 
 in situ a year or more the fibrous stricture may need dilatation with the divulsor 
 (Fig. 46). Otherwise traction may rupture the bronchial wall. The stenotic tissue 
 in cases of a few months' sojourn may be composed of granulations, in which case 
 a.xis-traction will safclv withdraw it. 
 
 the mucosa or a lateral branch. This jicrmits the head in some in- 
 stances to present its edge toward the observer. (ireat caution 
 is required in such instances. If the head is seized as at A, Fig. 180, 
 serious trauma may result in withdrawal, liy the ripi^ing effect of the 
 point, and tlie chances of its getting dragged out of the grip of the for- 
 ceps are great. If it is grasped by the stem we have the '"toggle and 
 ring'' action against tlie tube mouth (Fig. 177), and unless the tack is 
 very short the ])oint will cause trauma. The best method in the author's 
 experience with such cases is to push the presenting edge of the head 
 downward and laterally so as to luing up the point as far as possible. 
 Then a hook for the closed side cur\ed forcejis) is inserted under the 
 shank as close to the ]ioint as [jossible and thus the |)oinl can be brou.ght 
 up in the clear so that it can be seized with the forceps and withdrawn 
 into the tube mouth. If the head is too large to enter, the point is thus 
 protected while forcejis and bronchoscope are withilrawn together.
 
 282 
 
 MECHANICAL PROBLEMS OF FOREIGN BODY EXTRACTION. 
 
 Fa;. 179c. Schema illustrating the "mushroom anchor" problem of the brass- 
 headed upholstery tack. At A the tack is shown with the head bedded in swollen 
 mucosa. The bronchoscopist, looking through the bronchoscope, E, considering 
 himself lucky to have found the point of the tack, seizes it and starts to withdraw 
 it, making traction as shown by the dart in drawing B. The head of the tack 
 catches below a chondrial ring and rips in, tearing its way through the bronchial 
 wall (D) causing death liy mediastinal emphysema. This accident is still more 
 likely to occur if, as often happens, the tack-head is lodged in the orifice of the 
 upper lobe bronchus, F. But if the bronchoscopist swings the patient's head far 
 to the opposite side and makes axis-traction, as shown at C, the head of the tack 
 can be drawn through the swollen mucosa without anchoring itself in a cartilage. 
 Tf necessary, in addition, the lip of the bronchoscope can be used to repress the 
 angle, K, and the swollen mucosa, H. If the swollen mucosa, H, has been replaced 
 by fibrous tissue from many months' sojourn of the tack, the stenosis may require 
 dilatation with the divulsor, Fig. 46. 
 
 Fin. I79d. Problem of the upholstery tack with buried point. If pulled upon, 
 the imminent perforation of the mediastinum, as shown at A, will be completed, the 
 bronchus will be torn and death will follow even if the tack be removed, which is 
 of doubtful possibility. The proper method is gently to close the side curved for- 
 ceps on the shank of the tack near the head, push downward as shown by the dart, 
 in E, until the point emerges. Then the forceps are rotated to bring the point of 
 the tack away from the bronchial wall. It is usually better at this stage to release 
 the tack and grasp it firmly near the point for withdrawal, D. During stages A, B 
 and C the tack is grasped very gently.
 
 MKCIIAMCAL PROBLEMS OF FORKIGN Iit)tlY EXTRACTION. 
 
 283 
 
 111 makini,' the lateral movements referred to, the tube mouth is used 
 to push the forceps sidewise, the bronchoscopic lever being swung on its 
 fulcrum (Fig. i;i.">). Articles of jewelry, such as stick pins, usually re- 
 c|uire the same care that pertains to pins, in regard to getting the point 
 safely into the tube mouth. In withdrawal the head is apt to catch as 
 mentioned in regard to tacks, and the direction of traction must be mod- 
 ified accordingly. Nails of any except the smallest sizes are easily 
 found and usuallv present the same problems of extraction as mentioned 
 
 Fig. i/Oe. Schema illustrating the ''upper-Iobe-bronchus problem." combined 
 with the "rr.ushroom-anchor'' prol)lem and the author's twice-successful method for 
 their solution. Tlie patient being recumbent, the bronchoscopist looking down the 
 ri;,'ht main bronchus, M, sees the point of the tack projecting from the right upper- 
 lobe-bronchus, .\. He seizes the point with the side-curved forceps; then slides 
 down the bronchoscope to the position shown dotted at B. Next he pushes the 
 bronchoscopic lube-mouth downward and medianward, simultaneously moving the 
 patient's head to the right, thus swinging the bronchoscopic lever (Fig. 135) on its 
 fulcnnn, and dragging the tack downward and inward out of its bed, to the posi- 
 tion, D. Traction, as shown at C, will then safely and easily withdraw the tack 
 A very small bnmclioscope is essential. The lif of the bronchoscopic tube-mouth 
 must be used to pry the forceps down and over, and the lip must be brought close 
 to the tack just before the prying-pushing movement. S, right steni-bmnchus. 
 
 for pins. Thc'ir piunls are usually not sharp but their shape renders it 
 necessary to iret tlic | oiin irto the tube ir.oulh to ]ire\ent "tog.;"e and 
 ring" action. The !>ide cur\cd icirceps ( Fig. 'V.> I usuall\ get a belter hold 
 than straight jaws, and they can be used to better advantage in lateral 
 movements and in gras])ing pins, nails and tacks. Nails lodged head 
 uppermost niav present the proiilem of annular edema (Fig. 182). 
 
 Jervey ( I'.ib. '^Tlj, by a very ingeni(nts mclhod. extracted a very 
 large nail by carefully disengaging the ])oint and getting the nail into the 
 bronchoscope for li.ilf the nail's length and then pressing ihe nail tightly 
 to the wall of the tube b\- means of a hook tirniK' rotated.
 
 284 
 
 MECHANICAL PROBLE^!S OF FOREIGN BODY EXTRACTION. 
 
 Hollow iHctallic bodies. For foreign bodies presenting an opening 
 toward the observer, no instrument has proven more efficient than the 
 excellent one of Killian (Bib. Sli!), p. 26)- Different endoscopists will 
 prefer different handles, but the grooved expansile holder shown, fitted 
 to a suitable handle, cannot be excelled for firmly grasping and holding 
 such foreign bodies. An additional merit is that most of such bodies, 
 when so held, are in the best position for removal, whereas if grasped by 
 their edge there is more or less traumatism apt to be inflicted bv other 
 portions of their edge, if thin. If a large cylindrical hollow metallic body 
 does not [iresent its opening toward the operator, it may present the 
 problem of annular edema, Fig. 182. It may be turned if not too long, 
 but as a rule the method. Fig. 182. is preferable. 
 
 Fig. i8o. Schema of the mechanical problem of tack e.xtraction from the 
 bronchi. If the edge of the head presents, the point being in a branch bronchus 
 or imbedded in the wall, traction upon the head in the direction of the dart will 
 produce trauma and will probably be unsuccessful, .\fter turning, the point is 
 seized as at B, and traction is safe and successful. 
 
 Reino'al of open safety pins from the trachea and bronchi. The re- 
 moval of a closed safety pin presents only the ordinary mechanical prob- 
 lem of the long foreign body that must be grasped on end to jjrevent 
 the '"tog.gle and ring" difficulty. When the safety pin is open, but with 
 point down the problem is quite easy of solution. The near or spring end 
 of the pin is grasped and jiulled into the bronchoscope which closes the 
 pin. If the pm cannot be withdrawn completely into the tube it must at 
 least be drawn in until the "keeper" end of the pin is close up against 
 the tube mouth, not only to prevent the loss of the pin at the glottis, but 
 to prevent trauma by the usually sharp and hook-like "keeper." When 
 we have to deal with an open safety ])in lodged point up we have a difficult 
 problem, the proper execution of which is one of the most interesting in
 
 JIKCIIAKICAI. PKOItLF.MS 01' FOREIGN BODY EXTRACTION. 285 
 
 bronchoscoin-. If the pin is grasped and pulled out without closing the 
 pin. the point will inflict severe and probably fatal trauma. If the pin 
 is in the cervical trachea the patient will be subjected to less 
 risk in a removal by tracheotomy than by a ruthless endo- 
 scopic extraction. If an experienced and careful bronchoscopist is avail- 
 able, tracheotomy is a great injustice to the patient. It the intruder is in 
 the thoracic trachea, tracheotomy is absolutely contraindicated, and, more- 
 over, quite unnecessary. The pin must be closed and removed or the 
 point must be protected by the lip of the bronchoscope, as shown at C in 
 Fig. 178 in dealing with the point of straight pins. Then the point of 
 the safety i)in is grasped with the side curved forceps, Fig. 29, and pulled 
 into the bronchoscope. This leaves the "keeper" end out, but as the hook- 
 like end is down no trauma will be inflicted in withdrawal. But the pin 
 will almost certainly be lost at the glottis if care is not taken to be sure 
 that the greater plane of the keeper corresponds to the sagittal plane of 
 the glottis. If the safety pin is a small one it may be entirely pulled into 
 the bronchoscope by the ffirceps applied to the point. Large pins are too 
 stiff for this and rupture of the bronchus might result from the attempt. 
 Closure of an open safety pin lodged point upward is not a difficult pro- 
 cedure for those who will preliminarily practice it. The author's methoil 
 is shown schematically in h'ig. LSI. The most essential precaution is to 
 select frrjm the set of three a closer that has a ring of the jiroper size 
 for the ])arlicular pin in question. The ring should he large enough to 
 admit the s]iring end of the jiin, but should be no larger than necessary. 
 This is jjcst determined by trial with a similar pin, if one is brought 1)\' 
 the patient, or by trial with a ])in of similar size and shape as determined 
 with the aiil of a radi(jgrai)h. Due allowance must be made for radio- 
 graphic magnification, if any. The ring of the author's pin closer is oval 
 which is of fundamental imjjortance. Many clumsy imperfect models are 
 sold under the author's name. In case of an infant too small to ad- 
 mit a bronchoscope large enough to admit the closer through the lumen. 
 the closer may be passed into the trachea first and allowed to lie on the 
 posterior tracheal wall and interarytenoid space while the bronchoscope 
 is passed through the glottis anterior to the stem of the closer. The fork 
 is removed after the pin is closed and the removal is accomplished with 
 forceps. Should the endoscopist, from insufficient practice or con- 
 structive imperfection of the particular instrument at hand, be unable to 
 close the pin completely, he can at least bring the point away from the 
 wall and then the pniiU can be guarded by pushing the bronchoscope down 
 o\-er it. The iioint can then be seized with forceps if necessary, thougli 
 it will nsu.ally be found that the i)in is tightlv held bv keeping the broncho- 
 scope and pin closer in exact relation to each other after the fork is re-
 
 286 MECHANICAL PROBLEMS OE FOREIGX BODY EXTRACTION. 
 
 moved. The author has had two cases of open safety pins lodged point 
 ujiward at the bifurcation of the trachea, one of which was removed after 
 closure by the author's method (Fig. 181) ; and the other was removed 
 by pulling the point into the bronchoscope after liberating the point with 
 the lip of the bronchoscope and a hook as shown at C, Fig. 178. Thus 
 protecting the point during removal, the pin, held by the point with 
 forceps, was withdrawn, the pin being so turned that the "keeper" end of 
 the pin was made to correspond to the long diameter of the glottis. 
 Forceps, bronchoscope and pin were all withdrawn together. Hudson 
 Makuen has closed an open safety pin in the trachea bv the method de- 
 scribed above. To the writer's knowledge, these are the only three cases 
 of an open safety pin in the lower air passages. A number have occurred 
 
 A _^ 
 
 L 
 
 Fig. i8i. Schema illustrating the endoscopic closure of open safety pin,5 
 lodged point upward. The closer is passed down under pcular control until the 
 ring, R, is below the pin. The ring is then erected to the position shown dotted 
 at M, by moving the handle, H, downward to L and locking it there with the 
 latch, Z. The fork. A, is then inserted and, engaging the pin at the spring loop, 
 K, the pin is pushed into the ring, thus closing the pin. Slight rotation of the pin 
 with the forceps may he necessary to get the point into the keeper. 
 
 in the laryn.x. (Jpen safety pins seem to seek the esophagus, in which 
 location the author has had fourteen cases. 
 
 Removal of fish hooks and double [•ointcd tacks from the trachea. 
 These, if lodged point down present no difficulties though they must be 
 approached carefully to avoid causing perforation. If lodged point up 
 they must be dealt with in the most careful manner. The slightest pull 
 will complicate the problem by sinking the points into the wall. The au- 
 thor has never had a fish hook to deal with, but he has worked out a 
 number of methods which will be inentioned in connection with eso- 
 phageal foreign body problems. The author's experience with the double 
 pointed tack and staple has led him to favor turning this kind of intruder 
 end for end by means of the rotation forceps. Fig. :i;), or the full curved 
 hook shown at C in Fig. 17S, api>lied to the far (curved) end of the tack 
 or staple. This is only feasible with a relatively short intruder or a large 
 trachea. With a long staple in the infant trachea the best method is to
 
 MECIIAXJCAI. I'KUBLK-MS 01" l"ORIvIGN BODY EXTRACTION. 287 
 
 ■'coax" the intruder along gently under ocular guidance, never making 
 traction enough to hury the point deeply, and lifting the point with the 
 hook whenever it show^s any inclination to enter the wall. This is not 
 difiicult to do in the trachea, hut extreme dexterity is needed thus to get 
 the intruder through the glottis. Should the endoscopist fail in this, or 
 have doubts as to his ability to accomplish it, he is justified in doing a 
 tracheotomy for removal after, not before, he has brought the intruder 
 up to the subglottic region. The child must be kept in the Trendelen- 
 berg position in order to prevent the intruder dropping again into the 
 thoracic trachea and a bronchoscope must be left in the glottis during the 
 tracheotomy to forestall spasmodic stenosis. Under no circumstances 
 should the intruder be violently pulled through the glottis point first. 
 Mortality will almost certamly follow. Tracheotomy for the insertion 
 of a bronchoscope for the removal of inverted double pointed tacks from 
 the thoracic trachea or from the bronchi is a mistake. Better work can 
 be done through the mouth u]) to the point of getting the tack into the 
 subglottic region. In certain locations turning is facilitated by diverting 
 the points into branch bronchi as in the case illustrated by Figs. IHla, ISlb 
 and 181c. 
 
 The extraction of tightly fitting foreign bodies from the bronchi. 
 Annular edema. Bodies ^ncli as corks, jjebbles, marbles. Job's tears, 
 beads anfl the like are prdiiclled into the lower air passages with consid- 
 erable force by the insiiiratory blast, es])ecially by the deep inspiration 
 following cough. This ini])action prevents further ingress of air, and the 
 absorption of air below adds a negative ])ressure which increases the im- 
 paction and the tightness of the fit aids in quickly producing an annular 
 mucosal swelling (.\, Fig. 182) wdiich covers the j^resenting part of the 
 intruder so that all that is seen is a small surface in the center of an 
 acute edematous stenosis. If application of the forceps (F, Fig. 183) is 
 attempted they will not expand sufticiently to take in the intruder be- 
 cause of the annular edema .\. The author in such cases uses a forceps 
 (K) having very stiff expansive spring jaws so that when protruded 
 from the forceps cannula they will expand with sufficient force to press 
 out of the way (in the plane of their own expansion only, not annularly), 
 the swollen mucosa so as to permit of seizure of the foreign body, as 
 shown at B. The jaws of these forceps are narrow, because it is easier 
 to press outward a narrow portion of the swollen mucosa than a wide 
 one. Of course the jaws must not be so narrow as to cut, and in using 
 the forceps it is necessary to use great care to prevent damage. .\11 use 
 of such instriiments must be under the guidance of the eye. .\nother 
 very effectual way (big. 18:')) is to repress the swollen mucosa at one 
 point with liu- lip of the bronchoscope so that a hook may be jiassed
 
 288 
 
 MECHANICAL PROIU.KMS OF FOREIGN BODY EXTRACTION. 
 
 Fig. iSia. Radiographs, anteroposterior and lateral showing a staple in a posterior 
 hranch of the inferior-lobe bronchus, lO centimeters (4 inches) below the bifurcation 
 of the trachea, in a man aged 44 years. (Plates made by Dr. George W. Grier. 
 Author's case.)
 
 Mi:ciI.\.\K'AI. I'Kdlll.KMSOF I"()RF,IGi\ BODY EXTRACTION. 
 
 289 
 
 below the intruder w liich is drawn upward to a wider place where the 
 forceps can be appHed, or in some instances it can be imprisoned against 
 the tube mouth. One of the most difficult mechanical problems is w-here 
 a foreign body that completely occludes a bronchus into which it is tightly 
 drawn bv the absorption of air below, and that in addition has a conoidal 
 
 Fic. iXili. Schema illu'itratiiig a new method of removal of broiicliially-lodged 
 staples or double-pointed tacks. H, bronchoscope. A, swollen mucosa coverin;; 
 points of staple. At E the staple has been manipnlated upward with bronchoscopic 
 lip and hooks until the points are opposite the branch bronchial orifices, B, C. 
 Traction beins made in the direction of the dart (F), by means of the rotation 
 forceps, and counterpressure being made with the bronchoscopic lip on the points 
 of the staple, the points enter the branch bronchi and permit the staple to be turned 
 over and removed willi points trailing harmlessly behind (K). 
 
 Fk;. i8ic. Staph- (actual ^izc I removed from tlie right lung (see Fig. i8ia), 
 bloodlessly through tlie moutli, by bronchoscopy, after version as shown in Fig. 
 i8ib. 
 
 fiinn towanl the operator. The iirobleni is diliicult, especially if the in- 
 truder is hard and smooth because the forceps cannot get a large surface 
 of contact and hence slip. I'atience. however, will succeed. Eventually 
 a sufficiently tight Imlcl w ill In- niainlaiued lu withdraw the foreign body. 
 notwilh^taiiiling the iieg.itixe pressure which has ]Hilled it down and
 
 290 iMECHANICAL PROBLEMS OF FOREIGN BODY EXTRACTION. 
 
 which is still resisting its withdrawal. The author's heavier forceps are 
 used for this because tactile sensibility is not so essential as in friable 
 bodies. Strong forceps are needed, not for traction but for firm holding 
 on a hard smooth surface of a presenting cone. An illustrative case of 
 the author is the lump of coal removed from the bronchus of a Mara- 
 thon racer (see Chapter XXI). In the case of a rubber pencil eraser 
 Richardson (Bib. 448) used a screw-pointed instrument which he screwed 
 into the rubber as one would a corkscrew. Such a procedure, of 
 course, requires great care and skill. In some instances, the largest pos- 
 sible tube that would enter the bronchus without injury, has been used to 
 liberate the foreign body. In some such instances the intruder has been 
 coughed into the tube. Such cases have been reported by Tilley (Bib. 
 
 Fig. 182. Schema illustrating the problem of a tightly impacted foreign body 
 (C), above which an annular edema (A) prevents sufficient e.xpansion of the for- 
 ceps, F. Pushing on the forceps may force the foreign body into the mediastinum 
 or pleura. A special forceps (L) with very narrow and stiff-springed expansile 
 jaws (K) is used to displace the edematous mucosa (in the plane of their ex- 
 pansion only) as at B, so that they can be pushed down over the foreign body 
 sufficiently for a good grip on the foreign body (D). 
 
 546), Geo. L. Richards, Beck and others. As pointed out by Ingals 
 (Bib. 22G) oversized tubes must be used with caution, and this may 
 be said of every endoscopic procedure. A very interesting and quite 
 unique case of the aid of gravity in bronchoscopic foreign body extrac- 
 tion is that of Goldstein (Bib. 185) in which by placing the child in the 
 Trendelenberg position a marble after disimpaction was skillfully 
 dragged down hill with a bent bronchoscopic probe. 
 
 Extraction of soft friable bodies from the tracheo-bronchial tree. 
 Bodies that are soft, either by nature or from maceration in the secre- 
 tions of the tracheobronchial tree, besides the difficulty of disimpaction 
 present the difficulty of removal without crushing and permitting the frag- 
 ments to scatter. The essentials for successfully dealing with this prob- 
 lem are extremely delicate forceps unopposed by springs and a well de- 
 veloped sense of touch on the part of the operator. As elsewhere men-
 
 JIKCHANICAL PK'IBLKMS dl" FOREIGN liODV EXTRACTION. 
 
 291 
 
 tioned, heavy spring opposed foiccps prevent all delicacy of touch and 
 manipulation. The form of jaws used in Killian"s "bean" forceps 
 Fig. 32 is very useful in the removal of friable bodies and the author 
 uses jaws modeled after these adapted to his forceps. In the removal of 
 friable foreign bodies, if they are by accident broken up bv too firm a 
 grasp of the forceps, the question will arise how long the search should 
 be continued for every minute fragment. As a rule, fragments smaller 
 than 2 mm. in diameter have a very good chance of being coughed up 
 with the secretions which surround them. In some instances, howe\er, 
 foreign bodies of this size and smaller will cause multii)lc abscesses, so 
 that, as a rule, the bronchoscopist should jiersist in his search until he 
 
 Fig. 183. Schema illustrating the use of the lip of the bronchoscope in disini- 
 paction of foreign bodies. A and B show an annular edema above the foreign 
 body, F. At C the edematous mucosa is being repressed by the lip of the tube- 
 mouth, permitting insinuation of the hook, H, past one side of the foreign body, 
 which is then withdrawn to a convenient place for application of the forceps. 
 This repression by the lip is often used for purposes other tlian the insertion of 
 hooks. The lip of the esophagoscopc can he used in the same way. 
 
 has removed every fragment that he can find. Dottbtless quite a large 
 quantity of small particles of friable foreign bodies, such as jieanuts, will 
 be removed along with secretion by the author's "sponge pumping'' 
 method elsewhere described for the remoxal of secretions willmut an 
 aspirator. The sponges and secretions should be saved and washed to 
 find the jiarticles after bronchosco])y. .Veither the occasional success of 
 this nor the chance of a foreign bod\- being coughed uj) shoidd. however, 
 make one feel warranted in flelibcrately breaking a friable foreign body, 
 which cannot be considered as otherwise than a disaster. Claw forceps 
 are particularly un<lesirablc and beans should always be seized with the 
 plain foreign body forceps or "beau forceps" of delicate construction. By 
 delicate pressure with these, crushing can be avoided, whereas with claw 
 forceps the ])erforation of the claws is almost certain to cause the break- 
 ing up of tile intruder. In dealing with soft friable bodies of round shape
 
 292 MECHANICAL PROBLEMS OF FOREIGN BODY EXTRACTION. 
 
 of which the swollen mucosa overlaps the presenting end the stiff-springed 
 forceps above described cannot be used with sufficient delicacy and the 
 points would comminute the intruder. The tube mouth must be placed 
 in gentle contact with the foreign body and then moved laterally so that 
 the lip of the bronchoscope will draw aside a little crevice between the 
 intruder and the bronchial wall, in order that a hook may be inserted at 
 one side of the foreign body, which is, by means of the hook, withdrawn 
 to a wider place in the bronchial lumen where the delicate forceps jaws 
 (Fig. 183) can be, when fully expanded, closed over the foreign body. 
 The mechanical spoon (Fig. 40) is substituted for a hook, if the intruder 
 is in the main bronchus of an adult. Unless the swelling of the bronchial 
 mucosa, and also of the bean or similar absorbent foreign bodv is very" 
 great, the author has usually found it possible to use forceps in the ex- 
 traction of the foreign body ; but the manipulation must be extremely del- 
 icate, otherwise the intruder will be crushed and its fragments scattered. 
 The distance of the tube mouth during such manipulations is necessarily, 
 at the beginning, close to the foreign body. \\ hen the mechanical spoon, 
 the hook or the forceps are properly placed, the tube must be withdrawn 
 ahead of the foreign body as the latter is brought upward, unless it is 
 desired that the foreign body shall enter the tube. Holding of large soft 
 intruders tightly against the tube mouth cannot be done in case of very 
 friable foreign bodies without risk of crushing them. It is feasible in the 
 less friable bodies. Herbert Tilley reports (Bib. o-46) the bronchoscopic 
 removal of a green pea from the right bronchus of a man aged 63 under 
 local anesthesia, by a verv ingenious method. The bronchoscope was 
 passed down to the pea against which it was firmly pressed. A closely 
 fitting plug of cotton wool soaked in liquid paraffin ( petrolatum ) was 
 passed down the bronchoscope until it reached the foreign body. Then 
 by a sudden but sharp movement of withdrawal of the piston-plug the 
 I)ea was sucked into the lower end of the bronchoscope and removed to- 
 gether with the tube. Winslow (Bib. jT-") ) reports the recovery of a 
 desperate case after the bronchoscopic removal of the pulp of an almond 
 from the left bronchus of a child two years of age. Friable bodies such 
 as egg shells and thin glass, of each of which the author has had cases. 
 require an extremely delicate touch, for which the extremely delicate 
 forceps are necessary. 
 
 Removal of small animal objects from the trachco-hronchial tree. 
 The author has never had occasion to remove an insect. Flies and small 
 beetles are occasionally inhaled ; but are usually promptly coughed out. 
 Leeches seem to be of not rare endoscopic occurrence in Europe. Sarg- 
 non, Guisez and others have reported cases. Masterman, quoted by 
 Sir St. Clair Thomson (Bib. 539) states that a ten or twenty per cent
 
 MKCHAMCAL PKiJULE-MS OF FOREIGN" BODY EXTRACTION. ;20:! 
 
 solution of cocaine will cause a leech to loosen its hold from paralysis. 
 Doubtless ascarides and other living parasites would be equally suscep- 
 tible. In grasping any form of animal tissue the plain foreign body for- 
 ceps (Fig. SS I or the side curved forcej^s ( Fig. 'i'-i I are best. The broad 
 surface will hold without comminuting the intruder. 
 
 Extraction of foreign bodies from the ttppcr-lobc bronchus presents 
 interesting problems because of the impossibility of obtaining a lumen 
 presentation. Fortunately, it is exceedingly rare for foreign bodies to 
 disappear wholly into the upper-lobe bronchus. (If the author's six cases 
 all but one had been pushed there by previous operators. If a portion of 
 the foreign body projects the intruder can be removed by the method 
 shown in Fig. ]79e. A foreign body that has disappeared completely 
 within the upper-lobe bronchus can be removed liv the author's upper-lobe- 
 
 Fic. 18.3a. The aiitlior's iipper-lolje bronchus forceps for reaching "around tlie 
 corner" in the bronchoscopic extraction of foreign bodies. The jaws, B, can be 
 straightened out in passing them through the bronchoscope but will spring back into 
 their original shape on emerging at the distal bronchoscopic tube mouth. The end 
 of the forceps cannula, .\, is a spiral tube so as to pass over the curved jaws as 
 shown at C. 
 
 bronchus forceps ( l-'igs. 18:ia, l.s;Jb, LSMcj guided by the collaboration 
 with a fluorcscopist looking through the double-plane fluoroscope devised 
 for the author by Dr. George W. drier. 
 
 KUI.ES FOR ENDOSCOPIC FOREICN BODY EXTRACTION. 
 
 ]. Never endoscope a foreign body case un]ircpared, with the idea 
 of taking a preliminary look. 
 
 3. -Aijproach carefullv tlic >usiicctcil location of a foreign body, so 
 as not to override any portion of it. 
 
 •"1. .\void grasping a foreign body haslil\- as soon as seen. 
 
 4. The shape, size and ])osition of a foreign body and its relatimis 
 to surrounding structures siiould be studied before attemiiting to ajiply 
 the force|)s. ( l'"\ception cited in Rule in.) 
 
 5. 1 'rcliniin.-iry study of a foreign body sboubl be from a distance. 
 • 1. The tirst grasp of the forceps being the best, it sliould be well 
 
 planned beforehand so as to seize the proper ])art of the intruder. 
 
 7. \\ ith all long foreign bodies the motto should be "Search, not 
 for the foreign bodv, but for its nearer end." With pins, needles and
 
 294 
 
 MECHANICAL PROBLEMS OF FOREIGN' BODY EXTRACTION. 
 
 Fig. 18.3b. Schematic illustration of the author's upper-lobe-bronchus forceps in 
 position grasping a pin in an anteriorly ascending branch of the upper-lobe bronchus. 
 1", trachea; UL, upper-lobe bronchus; LB, left bronchus; SB, stem bronchus. 
 
 Fig. 183c. Upper-lobe-bronchus forceps in position in the living patient. 
 Radiograph originally made for localization, but incidentally showing curve re- 
 sumed on forceps after emerging from the bronchoscope.
 
 MKCIIANICAI, 1'KI)1U.1'MS 01* FOREICX BODY EXTRACTION. 295 
 
 the like, with pdim upward, search always for the point. Try to see it 
 first. 
 
 8. Rememhcr that a lung foreign body grasped near the middle 
 becomes, mechanically speaking, a ''toggle and ring." 
 
 9. Remember that the mortality to follow failure to remove a for- 
 eign body does not justify probably fatal violence in removal. 
 
 10. Laryngeallv lodged foreign bodies, because of the likelihood 
 of dislodgement and loss may be seized by any part first presented, and 
 plan of withdrawal determined afterward. 
 
 1 1 . For similar reasons laryngeal cases should be dealt with only 
 in the author's position, (Fig. 73a). 
 
 12. An esophagoscopy may be needed in a bronchoscopic case, or 
 a bronchoscopy in an esophageal case. Both kinds of tubes should be 
 sterile and ready in every case before starting. It is the unexpected that 
 hajjpens in foreign body endoscopy. 
 
 13. Do not pull on a foreign body unless it is properly grasped to 
 come away readily without trauma. Then do not pull hard. 
 
 14. Do no harm, if you cannot remove the foreign body. 
 
 Fluoroscopic bronchoscopy. In cases of foreign bodies which can- 
 not be found bronchoscopically. and yet which show clearly in the ray. 
 the bronchoscope may be ])assed to the suspected region and a probe may 
 be passed into a bronchus too small for the bronchoscope to enter. If 
 the body is of such density as to show in the fluoroscopic screen, the 
 fluoroscopist can give a promjit answer as to the localization, and this 
 will lie especially valuable if IkuIi a horizontal and a vertical screen can 
 be used.* Such a combination of screens would be valuable for fluoro- 
 scopic aid in the guiding of forceps for the removal of foreign bodies 
 located in such small peripheral bronchi that the intruder could not be 
 seen endoscopically. Personally, however, the author questions the ad- 
 visability of closing forceps by an\- other means than by the endoscopic 
 guidance of the eye. It happens only rarely that the foreign body is 
 visible on the fluoroscopic screen. When not visible fluoroscopically, a 
 radiograph should be taken with the probe in situ. Having limited by 
 the means previously mentioned, the number of bronchi to be searched, 
 the endoscopist can usually memorize two or three bronchi for separate 
 exposure, and by remembering the place it is possible to tell which one 
 of the bronchi is invaded. The Ijest probe for this purpose, in the au- 
 thor's experience, is the very small forceps which are only half the size 
 of the regular forceps. They are used closed which gives a very safe 
 
 •Di- I'leorRc \V. Giitr has ilevi.ii>(I for the author a double-plane fluoroscope 
 that promi.xt'.-' to be very u.sc-tul in oases of foreien bodies that are in .xucli minute 
 bronchi tliat thev cannot be found, and In cases of upper-lobe lironchu.-s invasion 
 provided the intruder is dense to the ray. General anesthesia should not lie used 
 l)ecause of the inllamniability of ether and because the patient should liold his 
 breath at command.
 
 296 MECHANICAL PROBLEMS OE FDREIGN BODY EXTRACTION. 
 
 probe pointed instrument, and if the intruder is found it can at once be 
 seized. If not found the forceps will show in a radiograph. The au- 
 thor has had two cases in which extraction of bronchially lodged foreign 
 bodies was previously tried by other endoscopists. Both were foreign 
 bodies of moderate size lodged in the right stem bronchus and not diffi- 
 cult of removal. In one case fluoroscopic bronchoscopy had been un- 
 successfully tried for over an hour under ether anesthesia. In the other 
 case two unsuccessful attempts under ether had been made, one of an 
 hour and the other of an hour and a half. It only required a few min- 
 utes in the author's clinic in each instance to remove the foreign bodies 
 without anesthesia, general or local, under ocular guidance by oral bron- 
 choscopv in the regular way. Tracheotomy had been done for the pre- 
 vious unsuccessful fluoroscopic bronchoscopies. For obvious reasons, 
 the author does not care to publish further details. Sufficient is here 
 given to emphasize the practical point that the author wishes to make. 
 Namely that fluoroscopic bronchoscopy is so deceptively easy from a 
 superficial theoretical point of view that it has been used unsuccessfully 
 in cases easily handled in the regular endoscopic way. The author 
 has been able to collect 12 cases of fluoroscopic bronchoscopy for foreign 
 bodies of which the following is an analysis : 
 
 Statistics of fluoroscopic bronchoscopy for foreign bodies by va- 
 rious operators: 
 
 Foreign body removed in 8 (66.7 per cent). 
 
 Foreign bodies not removed 4 (33.3 per cent). 
 
 Number of cases fatal within a week 5 (41.6 per cent). 
 
 Of fatal cases foreign body removed in 3 (60 percent). 
 
 Of fatal cases foreign body not removed 2 (40 per cent). 
 From the foregoing it is clear that fluoroscopic bronchoscopy be- 
 cause of its high mortality and its low percentage of successes, has noth- 
 ing to justify its use in any bronchially lodged foreign body case vuitil 
 after regular Killian, ocularly guided, endoscopic bronchoscopy has 
 failed. Personally the author would not use it until after another en- 
 doscopist besides himself had failed. Its use is, of course, only possible 
 in case of bodies very dense to the ray and such as can, by posture, be 
 seen clear of the heart and spinal shadows. Practically all of the cases 
 reported have required tracheotomy. Fluoroscopic bronchoscopy is an 
 improvement on the old method of using forceps blindly through the 
 tracheotomic wound ; but it is a step backward as compared to Killian 
 bronchoscopy, and, because of its high mortality and lack of success, it 
 is justifiable only when Killian bronchoscopy has failed. 
 
 Briinings has devised a lead-ended probe for radiographic localiza- 
 tion.
 
 CHAPTER XVI. 
 
 Foreign Bodies in the Bronchi for Prolonged Periods. 
 
 Cases of foreign bodies of prolonged sojourn, say a year or more, 
 in the bronchi require special consideration. Just what length of so- 
 journ is to be regarded as "'long," is, of course, difficult to say. The 
 secondar}' changes which make the ditierence requiring special consid- 
 eration set in after a few weeks, in some cases and a few months in 
 others, but bronchiarctia, bronchiectasis and abscess, in the author's ex- 
 perience, have been encountered only after a period of a year or more. 
 
 Etiology. The causes leading to the prolonged sojourn of a for- 
 eign body may be classified under three heads: 
 
 1. Ignorance of its presence. 
 
 2. Inability to make a diagnosis when suspected. 
 
 1 High mortality attending efforts at removal in the pre-bron- 
 choscopic days. 
 
 The cases hereinafter reported as well as common experience show 
 that, strange as it may seem, practitioners are heedless of, and even scofif 
 at. the patient's suspicions that a long previously aspirated foreign body 
 is the cause of present symptoms. This is largely due to failure to recog- 
 nize and to teach in colleges the fact that there is a prolonged symptom- 
 less quiescent period after the aspiration of a foreign body into the lungs. 
 When a patient states that he has neither felt anything nor coughed for 
 months after the suspected accident, theoretically the presence of a for- 
 eign body in a lironchus seems impossible; yet, practically, we know that 
 is just the usual course of such cases. The difficulty of diagnosis prior 
 to the days of radiography, and still existing in cases of intruders not 
 dense to the ray, has been an important factor in the etiology of the cases 
 we now see. Another imjiortant factor is that prior to the days of 
 bronchosco])y the then stale of intrathoracic surgerj- rendered interven- 
 tion inadvisable until after abscess formation. For surgical safety, as 
 well as because the abscess often could not be located prior to the de-
 
 298 FOREIGN BODIES IN BRONCHI FOR PROLONGED PERIODS. 
 
 velopment of radiography, waiting for invasion of the pleura was usually 
 advised. 
 
 Pathologx.* Doubtless verv minute bodies become encysted or 
 invade the interlobular connective tissue, as in anthracosis, but aspirated 
 foreign bodies of larger size apparently rarely, if ever, become encysted, 
 though, as in one of the author's cases, the foreign body may migrate 
 and become somewhat "pocketed." It is evident from bronchoscopic find- 
 ings that a foreign body too large for anthracosis, by gravity, as well as 
 by aspiration, reaches the smallest bronchus it can enter, where it stops. 
 Later negative pressure draws it still further downward. By mechanical 
 irritation alone, or, more likely, from this combined with pyogenic or- 
 ganisms carried down with the foreign body, there results a productive 
 inflammation which first completely occludes the involved bronchus with 
 swollen mucosa (plus the bulk of the foreign body itself) ending in ab- 
 scess of the lung below the foreign body. Later, sloughing or ulcer- 
 ation follows in the tissues surrounding the foreign body, permitting the 
 slow escape of discharges, which because of the lessened expulsive cough 
 efifort from below consequent on the obstruction, tend to accumulate, 
 producing the condition of bronchiectasis above the obstruction. In 
 time, the obstruction owing to the productive inflammation becomes a 
 cicatricial stricture. Below the stricture, the abscess cavity becomes, in 
 a sense, a bronchiectatic cavity, also. The loss of the cilia and even 
 of the epithelium itself follows, and increases the stagnation of the se- 
 cretions. The bronchial wall may be destroyed by ulceration and chon- 
 drial necrosis, and the foreign body may wander. The law of gravity 
 would lead one to expect to find the foreign body at the bottom of the 
 cavity in the formation of which it has been the chief etiologic factor. 
 In two of the author's cases it was at the top. close under the stricture. 
 The following seems a plausible explanation : The abscess, of course, 
 forms below the obstruction, but by the time the substrictural bron- 
 chiectatic cavity has been produced, the foreign body has become suf- 
 ficiently fixed, by organization of a part of the surrounding granulation 
 tissue, to hold the body in its place at the top of the cavity which it 
 has caused. The development of a stricture above the foreign body is 
 plausibly explained by the ulceration which is more or less annular. 
 Such ulceration in any channel or tube in the body always results in 
 more or less constriction of the lumen when the scar tissue contracts. 
 That it does not occur to the same extent immediatelv below the foreign 
 body is probably due to the conditions which cause the substrictural bron- 
 chiectasis. The reader interested in the etiolog)- and pathogenesis of 
 
 *Ab.stracted fwith revision and additions) from a paper read by the autlior at 
 the meeting of the I.ar.vnsoloKical Section of the American Medical Association. 
 June, 1912.
 
 FOKIvICN BODIES I.N llNi i.\ ClI I I'OK I'Ri i|,i >.\GF.I) PI'.KIOUS. 399 
 
 bronchiectasis is referred to the excellent article of C. P. Howard (Bib. 
 214). In some cases communication with the subjacent bronchi is 
 permanently closed by intiammatory sequelae, and the abscess may be- 
 come walled off and so remain for years. Sooner or later, however, if 
 the patient survive, the abscess, probably, will burst into the same bron- 
 chus or a branch, or it will burst into the pleura. There seems to be a 
 strong tendency for foreign bodies to work toward the periphery as 
 shown by the consecutive radiographs in one of the author's unsuccess- 
 ful cases. This seems to be the tendency whether the abscess is closed 
 off from broncliial drainage or not, but the history of nearly all cases 
 seems to show that drainage is usually interrupted for a greater or 
 lesser time, so that all cases are closed abscesses for part of the time. 
 Atelectasis of the occluded lung area is usual with foreign bodies that 
 occlude a bronchus, and, if prolonged, eventual functional destruction 
 by the secondary processes is the usual result. Emphysema and not 
 atelectasis may in rare instances follow the presence of a foreign body 
 as shown by Iglauer (Bib. 22:!). Cases of foreign bodies, such as 
 pins, that because of their small diameter are not obstructive, usually 
 are not quickly followed Ijy secondary changes, as noted by James ^\ . 
 MacFadane at thoracotomy. Eventually, however, secondary inflam- 
 matory sequelae will cause occlusion of the invaded branch bronchus and 
 all the sequelae of a pent up infected focus may be looked for. Gan- 
 grenous bronchitis and pneumonitis have been recorded as following the 
 aspiration of a foreign body, but they are very rare sequelae. 
 
 A distinction should be made between an area of ''drowned lung" 
 (natural ])assages full of pus) and a true abscess cavity. 
 
 Prognosis. If unremoved the foreign body will almost certainly 
 prove fatal. If removed most cases will recover without further local 
 treatment. A few will re(|uire bronchoscopic attention to drain- 
 age. All cases will need a general antituberculous regime, and if this can 
 be followed the prognosis is good. In a small percentage of cases exten- 
 sive secondary changes as in one of the author's cases (Edward M.) an 
 infective embolus from the lung or endocardial focus, before complete 
 resolution has ensued, may lodge in a vital spot and end fatally, just as 
 sometimes hajipens without lironchosco])ic or other remo\al. 
 
 Indications for bronchoscopy for foreign body of prolonged sojourn. 
 r.ronclioscoi)y for removal is urgently indicated in every case in which 
 there is any expectoration. In cases with ,i histon,' of intcnnitlcnt ex- 
 pectoration of foul pus. it is better to do the bronchoscoijy during the 
 discharging i)erif)d, rather than in the dry interval, so that following the 
 pus to its source will lead the bnnKlioscopist to the foreign bodv. Feeble- 
 ness, even ;ipproaching a moribund condition, is no contraindication, as
 
 300 FOREIGN BODIES IN BRONCHI FOR PROLONGED PERIODS. 
 
 shown by the author's case (Mrs. K.), provided no anesthetic, general 
 or local, is used. In cases in which there is a long period of cessation of 
 discharge even though the patient is in good health, an exploratory bron- 
 choscopy is indicated. If m such a "dry" case, a thick barrier is found 
 bronchoscopically with no fistulous opening, and the radiograph shows 
 an abscess close to the external wall of the chest, external operation by 
 the general surgeon may be indicated. Of course, it is not known how 
 frequently foreign bodies may be the cause of bronchiectasis, but the 
 similaritv of the symptoms in bronchiectasis and in foreign bodies in the 
 bronchi, would certainly render exploratory bronchoscopy advisable even 
 in a case with a radiograph negative as to foreign body. The same may 
 be said of circumscribed pulmonary abscess, especially if tuberculosis can 
 be excluded, though it is not impossible that a tuberculous process may 
 exist primary or secondary to foreign body lodgment. 
 
 In all cases of doubt bronchoscopy is a harmless procedure that 
 should be done anyway. 
 
 Symptomatology and diagnosis. After the aspiration of a foreign 
 body into the trachea and bronchi, there is a longer or shorter period of 
 perfect health in which the patient has no symptoms whatever. It is 
 often difficult to convince the family, and even the family medical ad- 
 visor, that a foreign body can be present and not produce any cough, 
 bloody expectoration, dyspnea, rise of temperature, or any other s\mptom. 
 Nevertheless, nearly all small foreign bodies that reach the bronchi do not 
 produce any such s\mptoms for a variable period of weeks or sometimes 
 months. Then begins a gradual turn to failing health, the exact cause of 
 which is often unsuspected. There may be slight cough with scanty ex- 
 pectoration, slight temperature elevation, some malaise, with slight loss 
 of weight, and altogether a picture of incipient tuberculosis, which, in- 
 deed, has been, undoubtedly, the diagnosis in many cases. The close 
 parallel between the symptoms noted in these cases and in pulmonary 
 tuberculosis even to the clubbing of the fingers (see case of Edward M.) 
 would seem to render it advisable to Stispect the presence of a foreign 
 body in every case of seeming tuberculosis, in wdiich no bacilli are found 
 in a purulent sputum, and especially if the symptoms are confined to the 
 lower lobe, particularly the right lower lobe. This would still leave out 
 the cases of foreign body in which a tuberculous infection has preceded, 
 or, more often, followed the aspiration of a foreign body. Tw'o of the 
 author's cases (Brooks G. and Mary X.) Iiad such marked signs of 
 pleurisy that they had been previously tapped without getting fluid. In- 
 gals reports a similar case. The erroneous diagnosis of pleural disease in 
 these and other cases of foreign body in the lungs has been ably pointed 
 out by Boyce (Bib 14).
 
 i-iiui;if..\ r,(iini;s in liKdNCiii imr I'koi.dngkd periods. 301 
 
 The use of the radiograph as a routine procedure would certainly 
 seem indicated in the diagnosis of thoracic disease.* 
 
 'J'rcdtiitcnt. I'us. granulomata, blood and stricture are the obstacles 
 to be overcome in dealing with foreign bodies of long duration. As 
 large a quantity of pus as possible should be removed by posture and vol- 
 untary cough before bronchoscopy. As a rule the morning is the worst 
 time to operate because of the accumulation over night. By afternoon 
 much pus can have been expectorated. Children can be held up by the 
 ankles during coughing jjaroxysms. Adults may be placed on the sound 
 side, pillowless, on a bed elevated high at the foot. Antibechics, bad at 
 any time, should be esjiecially forbidden during the forty-eight hours pre- 
 ceding bronchoscopy. What pus remains should be removed at the first 
 stage of bronchoscopv by the author's "sponge pumping" process pre- 
 viously herein described. For this, work without anesthetic is a great 
 help. If anesthesia is used, as the author did in some of the adult cases, 
 the cough reflex should not be altogether abolished. It is very essential 
 in the preliminary examination to use the sponges very gently in getting 
 out the pus, so as to avoid, if possible, traumatism to the granulations, 
 which may cause quite a good deal of bleeding and thus obscure the 
 field. 'Jf course, after the first survey of the field, it is often necessary 
 to remove the granulations with forceps. During this, the sponging can 
 be fairly vigorous, but removal of the granulations should not be begun 
 until after the preliminary survey. It will require, in some instances, as 
 much as three-quarters of an hour to get the field entirely clear of gran- 
 ulation tissue, pus and secretion, and to get the blood wiped away and 
 the bleeding stopped. This is usually time well spent, because it 
 enables more prompt work when the foreign body finally comes into 
 view. The difficulties of contending with abundant granulation tissue, 
 is well described by Ingals, as follows: "The moment this tissue was 
 disturbed, bleeding occurred which obscured the field of vision and caused 
 great delay from the necessity of swabbing away the blood. This is one 
 of the greatest difficulties when granulomas are encountered in these 
 cases, and one which occupies at least nine-tenths of the operators time. 
 When bleeding has been checked and tlic field of vision once more 
 cleared, the next portion of granulation tissue that is removed causes a 
 repetition of the whole procedure; and this is likely to occur repeatedly 
 before the foreign bcjdy can be seen." This statement has absolutely 
 nothing to do with the form of distal inuniiiiation which lugals uses. 
 
 •.lust a.i tlu'.'ic pagi'S no to pres.s, I >r. fleorge i>. Richards made a diagnosis of 
 a foieiKn l)0(3.v In the lung- upon aif unexplained U'ucocytosl.s, cough, negative 
 .sputum examination and jihysical .><iKn» of bronchial obstiuction. Diagnosis 
 vi-rifled b.v radioHT-aphir tlndins: and bi-onchoscopic removal of a tack of the 
 a.splration of which the patient had no recollection.
 
 302 FOREIGN BODIES IN BROXCHI FOR PROLONGED PERIODS. 
 
 There is no form of illr.mination which wiU permit the observer to see 
 through a pool of blood. 
 
 The probability of location of the foreign body at the top. instead 
 of at the bottom of the abscess cavity in strictured cases, is a point of 
 greatest importance, as without the advice of Dr. Boyce on this point, 
 the search in two of the author's subsequently mentioned cases would 
 have been prolonged, and might have been futile ; because the foreign 
 body was not in either instance free in the cavity. On the contrary, it 
 was fixed and bedded in granulation and fibrous tissue, external to the 
 bronchial wall, through which it had eroded its way. The location of the 
 intruder outward under the overhang of the cicatricial stricture rendered 
 the finding of the foreign body difficult, if not impossible, without dila- 
 tation of the superjacent stricture. Xo useful forceps could have been 
 inserted through the strictures, in the two cases referred to ; the foreign 
 body could not have been found and certainly could not have been with- 
 drawn. If withdrawal were possible, trauma would have been extensive, 
 and probably fatal. The dilatation of the purely cicatricial tissue of 
 the stricture was harmless. Further, and very important, the dilatation 
 improved the drainage, so that Xature could care for the lesions result- 
 ing from the long sojourn of the intruder. 
 
 The method of dilatation by divulsion used in these cases possesses 
 the following advantages : 
 
 1. It is safe because it is under the guidance of the eye and the 
 trained touch, by which both the direction and the extent of the dila- 
 tation are accurately limited at will. 
 
 2. It does not require tracheotomj' in any case. 
 
 3. There is no danger of pushing the foreign body downward as 
 is possible in certain cases, if anything in the shape of a bougie were to 
 be used. Pushing a foreign body downward not onlv makes removal 
 more difficult but involves serious risk of rupturing the bronchus. 
 
 Jr. It is, obviously, better adapted than tent dilatation to foreign 
 body cases, and is. in any case, much safer and simpler. 
 
 The method is simple. The divulsor. Fig. 4.'), is inserted, under 
 guidance of the eye, into the stricture which is stretched to the maxi- 
 mum expansion of the instrument. Then the larger divulsor, Fig. 4(5, is 
 used to its maximum. This will jjermit the entrance of the closed 
 side curved forceps, Fig. 20, with which the cavity can be probed. 
 When the intruder is felt the forceps can be expanded and tlie intruder 
 grasped ; and if it does not come readily through the stricture the for- 
 ceps can be rotated, if the foreign body be not such as to cause danger- 
 ous trauma. A tack or pin wrongly grasped cannot be pulled through 
 a firm cicatricial stricture. It is necessary to release the hold at the top
 
 FOKKK^X HoniES IN" BRONCHI FOR rRUI.ONGED PERIODS. 303 
 
 (near end in tlu- recumbent jiatient ) of the cavity, and examine the po- 
 sition and sliape of the foreign body and get a fresh hold planned ac- 
 cording to the mechanical problem presented. In some instances the 
 cavity can be explored by gently forcing the conical ended tube (Fig. 
 IS), into the already partially dilated stricture. In case of tacks lodged 
 point upward the point may project upward through the stricture. If 
 traction demonstrates a firm strictural obstruction, the dilator, Fig. 40, 
 which is hollow may be pushed down outside the stem of the tack, and 
 the stricture dilated without risk of pushing the tack downward. The 
 conical ended tube may be used, the point of tack seized and then the 
 stricture dilated by forcing the bronchoscope, forceps and tack all down 
 together, before withdrawal. 
 
 In one case of prolonged sojourn the stricture was so firm and 
 unyielding that prolonged intubation with metallic tubes was re<|uired. 
 A tracheotomy was done and the tube inserted, removed at intervals of 
 a few days and reinserted under local anesthesia. For further details 
 see Hriinings' book ( Hib. (52) or Mr. Howarth's excellent translation 
 (Bib. 208). 
 
 In one of the author's cases (Mrs. K.) recited below, instead of a 
 stricture there was a mass of cicatricial tissue with small fistulae tilled 
 with buds of granulation tissue. This ])lug of cicatricial tissue, as shown 
 by the radiograph, was about two centimeters in depth and beyond lay 
 the foreign body. Fortunately the accurate advice of the radiographer, 
 Dr. George C. Johnston, enabled the author to excise this intervening 
 tissue and thus to reach and extract the foreign body. Without the 
 guidance of an extraordinarily good radiogra])h showing the bronchus 
 for a sufficient distance above the tissue barrier, thus giving a line of 
 direction, such removal is exceedingly hazardous as to both life and 
 successful foreign body removal. Fluoroscopic guidance is unsafe un- 
 less the fluoroscopy is done by two independent fluoroscopists, one for 
 the vertical and one for the horizontal screen, while the bronchoscopist 
 follows the dictates of the endoscopic image and of this general sense 
 of direction. Even under these circumstances the procedure is hazard- 
 ous. 
 
 Particular care must be taken not to lose the foreign bt)dy from 
 the gras]) of the forceps. The risk involved is especially great if the 
 intruder be large enough to be ol)structivc because if it should enter 
 and occlude the sound bronchus, the diseased side may be so atrophied 
 as to be useless and the jiatient may die before the intruder can be 
 again grasped and removed. This accident happened to Hinsl)erg. 
 
 /Iftcr-care. Local treatment has not been necessary in the author's 
 cases, of 2, 7, 10 and 2U years resjjectively. If, however, there seems
 
 304 FOREIGN BODIES IN BRONCHI FOR PROLONGED PERIODS. 
 
 to be a serious degree of bronchiectatic pus retention, or the patient 
 fails to improve, after a few months, a radiograph should be made and 
 compared with one made immediately after the foreign body removal. 
 All of the author's cases were thus examined and all were making such 
 excellent progress that nothing further was done. In case, however, 
 of serious lack of drainage repeated dilatations and intubations of the 
 strictural obstruction to drainage is indicated. This was done by Kil- 
 lian and Briinings in the case referred to and will be necessary in a cer- 
 tain proportion of cases. 
 
 General treatment after the removal of a foreign body of prolonged 
 sojourn is quite essential. Milk, eggs, rest in bed oiU doors are indi- 
 cated. In fact the entire anti-tuberculous regime is highly efficient. 
 
 author's BROXCIIOSCOPIC C.XSES OF FOREIGN BODY OF PROLONGED SOJOURN. 
 
 Brass fastener reinozrd by oral broiielwscof'y from right broncluis 
 after sez'eii years' sojourn. Alary X., aged 2?). was seen in consultation 
 with Drs. J. Sotis Cohen, D. Braden Kyle and Tello d" Apery. The patient 
 gave a history of continual cough and foul, yellowish expectoration ff^- 
 about a year and a half, during which time she had an irregular tempera- 
 ture elevation and had lost weight. For seven years she had been sub- 
 ject to severe cough witii expectoration during the winter, these symp- 
 toms disappearing in summer. The diagnosis of pulmonary tuberculosis 
 had been made by a number of physicians. The foregoing is in brief the 
 history she gave on admission to Jefferson College Hospital. 
 
 Radiographic examination. Dr. Solis Cohen in consultation with 
 Dr. d'Apery found both apices free from disease. The only abnormal 
 physical signs were slight impairment of resonance at the right base, with 
 dim.inished voice and breath sounds. As these, in his opinion, did not 
 sufficiently account for the symptoms, he referred the case to Dr, Willis 
 F. Manges for radiographic study. Dr. Manges in a beautiful stereo- 
 scopic radiograph (Fig. 184) showed a stricture of the right bronchus, 
 with a metallic body resembling an upholsterer's tack, point upward, 
 below the stricture and behind the bronchus. The patient remembered 
 having "swallowed" a price tag fastener seven years before, but as she 
 was told that it would pass harmlessly, she had forgotten the occurrence. 
 She had had no symptoms whatever until the winter following the acci- 
 dent. Symptoms recurred each winter. 
 
 Bronchoscopy. At Jeiiferson College Hospital before the members 
 of the American Laryngological Association, the author passed a broncho- 
 scope through the mouth. The trachea was full of foul, purulent secre- 
 tion which was removed by "sponge pumping," the patient being kept
 
 FOREIGN nODII-S IN liKONCHI FOR PROLONGliD PERIODS. 305 
 
 only partially under cIIkt Id i^ain Ihc aid of the cough retlex/'' The last 
 of the secretion removed from the right bronchus was mixed with blood. 
 The right main bronchus, just below the orifice of the middle lobe bron- 
 chus, was occluded by a tirm stricture, the lumen of which was a mere 
 slit, extending about ■'< mm. laterally, and with mi apiirecialile antero- 
 posterior diameter, the anterior and posterior edges being in contact. At 
 each coughing efl'ort, bloody secretion was forced through the slit. The 
 stricture was dilated with the author's divulsors, in the direction of the 
 narrowest diameter. Then the source of the bleeding .md the blood- 
 stained secretion was found to be a mass of granulations located below 
 the stricture and j^osteriorly. Dclow this was a large cavity from which 
 a <|uantity of very thicl< pus was removed. This pus was not foul like 
 the tracheal pus. ( Possibl_\- the author's olfactory sense was by this time 
 obtuiided.) On exploration, with bronchoscopic lateral displacement, the 
 mass of granulation tissue at the top of the cavity posteriorly was found 
 to protrude from an accessory ca\ity, extending posteriorly and median- 
 ward, outside of the bronchus. ( )n removal of the granulation tissue, 
 the foreign body was fnuiul and reni()\eil. It ])roved to be a jirice tag 
 fastener (Fig. 185). 
 
 Patlwlugist's iwf'ort. The granulatidn tissue removed was examined 
 by Dr. Ernest W \\ illell>, who reported as follows: Specimen consisted 
 of several very small pieces of tissue. Microscopic examination shows a 
 covering of stratified s(|uamous epithelium which has normal appearance 
 but is thickened considerably at some points. T'.eneatli the epillieliuni 
 there was a mass of connective tissue showing manv mast-cells, fibro- 
 blasts, new blood-vessels and some older, more fibrous areas. There is 
 also considerable niund-cell inl'illration. The jirocess appears t(i be a 
 chronic infiamm.-ilory (iiie. the exact n;ilnre (if which is not exidenl fnini 
 microscopic examination." 
 
 Subsequent history. The p:ilient in:ide an entire and complete re- 
 covery, and one year afterward, Dr. d'.\]iery reported that she was work- 
 ing at her occujiation in the stocking factory, in possession of perfect 
 health, the cough and expectoration having beer, totally absent for the 
 past winter, the first out of seven winters. The patient was exhibited 
 the following year at tiie meeting of the American Medical .Association 
 and now, three years later, is still in perfect health. 
 
 Lead-alloy collar button in riglit bronchus ten years. Renioivl by 
 oral bronchosecf'y. Brooks G., aged eighteen years, small, frail and 
 undevelojied for his age, ga\e a history of ])neumonia eight years before 
 (.1003), followed by pleurisy and empyema, which one year later ( l!Hi| i 
 
 •This and the two fuHuwiiic cH.sr.^ oocurrpd a luiriilKr of yi-avs tiKO. In latfi- 
 ca.>!e.x the author has found it advantnKPous to woiU with local anesthesia in 
 adults, witliout any anesthesia in cliildren.
 
 30(1 
 
 FOREIGN BODIES IN BRONCHI FOR PROLONGED PERIODS. 
 
 was tapped and drained. Only a very small amount of pus was obtained 
 and drainage during three months was very unsatisfactory. Temporary 
 improvements were followed by relapses. Chills were attributed to a 
 supposed malarial infection while living in \'irginia. An eminent in- 
 ternist diagnosticated pulmonary tuberculosis, since which time treatment 
 had been chieHv climatic, Ijv residence in Arizona. The bov never re- 
 
 Fic. 184. — Radiograph by Dr. Willis F. Manges, (Philadelphia) showing price- 
 tag fastener which had been seven years in the right bronchus of a girl of 2,3 years. 
 (Mary N.). Fastener removed by oral bronchoscopy after bronchoscopic dilatation 
 of the bronchia! stricture (Anther's case). 
 
 Fig. 185. — Price-tag fastener lodged for seven years in the lung of a girl aged 
 23 years. Removed bronchoscopically through the mouth after dilatation of the 
 overlying bronchial stricture. Only one branch wire shows in the radiograph, 
 because the two were in line (Author's case). 
 
 gained his health sufihcientlv to dispense with a nurse. He was frail 
 and suffered continually from cough, usually with [)urulent sputum, fre- 
 (|ucntly pink-stained, and occasionally of foul odor. He had low, irreg- 
 ular temperature elevation very suggestive of tuberculosis, but sputum 
 examination was always negative. Dr. J. C. Roper, of the New York 
 Hospital, after careful sputum exannnations, found no tubercle bacilli 
 and no elastic tissue.
 
 I'OKlvK'.N ]'.()l)llis I.N liKONCIU FUK I'KULONGEU PICKIODS. 
 
 :i07 
 
 Rcfort of physical e.viiniiuiliun (Dr. James T. Edijerion and Dr. 
 John W. Boycc). Patient is frail, underweight, pigcon-hreasted, and has 
 marked dextrocardia: a;>iees free from (h'sease. l^hysical sign-; are con- 
 lined to base of right hmg. Low down posteriorly, and extending to 
 edges of lung, both breath and \fjice sounds were increased with a sug- 
 gestion of amphoric breathing and whispered pectoriloquy. Xo change 
 in percussion note. We are unable tr> demonstrate either tympany, 
 cracked-pot note or W'intrich's change of tone when mouth is open. 
 
 Fic;. iSS. — R;uli<)j.'r;iiil) In I )r. l.iui- (,i(.^ury CUlc ( .W'w York) sliovving 
 lead collar Imttdii (iniiui-- lu-;iil ) in rii^lit lung of a boy of eighteen years. Re- 
 moved lironclioscopioally tlir()ii,i;li tin- nioutli, after diviilsinn of tile iivcrlyiiiK 
 stricture (Author's case). 
 
 Such was the history and the condition of the patient when taken 
 to Dr. James 1. Kdgerton. of New York City. Unlike his predecessors. 
 Dr. Edgerton did not conclude that all the physical signs were attribut- 
 able to the secondary changes, following the suppo.sed empyema of eight 
 years before, and sought the aid of Dr. Lewis Gregory Cole, of Xew 
 York City, who located with wonderful accuracy by radiographic tri- 
 angulation. a portion of a lead collar button, midvyay between the angle 
 of the scapula and the si)ine, ii. I cm. from the posterior \yall of the 
 chest. The collar button consisted onl\- of a base and post, willuuit .i 
 top, giying the a|i]:ear;incc of a ri\et as seen in the radiogra]ili i big.
 
 308 FOREIGN BODIES IN liRONCHI FOR PROLONGED PERIODS. 
 
 isii). The parents remeinljered tliat the child had "choked ten years 
 (symptoms eight years) i)reviously on the collar button ; and thev had re- 
 iterated to numerous medical attendants their suspicion that the collar 
 button might be the cause-of all the symptoms, and in recent years they 
 had even requested that a radiograph be taken." I'.ut the scoffing at lay 
 opinions had silenced them. \)v. Edgerton brought the boy to the author. 
 Bronchoscopy. On passing the bronchoscope through the larynx, 
 a large quantity of very foul, blood-stained pus was continually being 
 coughed up from below. This coughing could, of course, have been 
 stopped by deep general anesthesia, but the cough reflex was preserved 
 under slight ether anesthesia, as an invaluable aid in ridding the lower 
 air passages of the foul secretion, which obscured everything. After 
 the fluid was removed from the trachea by "sponge pumping," it w.is 
 easy to see that the pus was coming from the right bronchus. This bron- 
 chus was pumped out and then it could be seen that almost all the right 
 bronchus was a bronchiectatic cavity with a cicatricial bottom, at the 
 right edge of which was a small strictural o|iening, about "^ mm. in 
 
 4t^ 
 
 Fu;. 187. — Portion of lead collar Imtton (kind used liv laundries) removed by 
 oral bronchoscopy, from the lung of a hoy ( Urooks. G.) aged eighteen year.s 
 (Autlior's case). 
 
 diameter. A cicatricial web occluded about two-thirds of the bronchial 
 lumen just above the stricture and this web at its right end cur\e(l down- 
 ward forming part of the edge of the stricture. The apertures of the 
 upper and middle lobe bronchi seemed more than usually oval in out- 
 line, though of this it was difficult to be certain, and the time could not 
 be spared for careful examination, since it was practicall\- certain that 
 the collar button was below the stricture, which therefore must be 
 dilated. The di\ulsor (Fig. 1"i 1 was passed and readily entered the 
 lumen of the stricture. The divulsion to the full extent of the instru- 
 ment (1 cm.) did not require great force. After the withdrawal of the 
 small dilator, the large dilator ( Fig. 4ii ) was introduced and expanded 
 and allowed to remain //; .v(7(/ for a few minutes. Next, the cavity below 
 the stricture was wii)ed out with small bronchoscopic swabs. Basing 
 his judgment on the fact that the i)hysical signs as above given were be- 
 low the point at which Dr. Cole located the foreign body. Dr. lioyce ad- 
 vised the author that the collar button would be found at the top and 
 not the bottom of the aliscess cavity. Acting on this advice, a small 
 patch of granulation tissue was found immediately uniler the overhang-
 
 VOKKIGN I'.ODIKS IN liKOXClll l-i iK I'KoLnNGKU 1'KKIkDS. 309 
 
 ]iig left edge of the dilated strictural openings. During exploration of 
 this granulation tissue with the jaws of the foreeps (Fig. 2!)) the collar 
 button was felt and removed. -A.t the first attempt, the tip of the post 
 of the button came away, permitting the removal of the balance of the 
 button (Fig. ^^7) edgewise. The boy returned to his home a few days 
 later, and four months afterwards, entered college in fairly good health. 
 One year after the operation he was reported by Dr. H. A\'. Fenner, of 
 Tucson, .Arizona, to be free from cough and expectoration and other- 
 wise healthy and normal in every way. Two years later he won the 
 tennis championship of Colorado after a long and arduous training and 
 tournament. Xow. three years after the removal, he is in good health 
 and averages uj) to normal development for his age except in height. 
 Radiographic study by Dr. Cole at various stages of convalescence gave 
 accurate graphic data on local progress, and the skillful care of Drs. 
 Edgerton and Fenner contributed largely to recovery. 
 
 Brass-headed tack in rhjlit bronchus two years. Rcmoird h\ oral 
 bronchoscopy. 
 
 T 
 
 Fig. i88. — Urass-headcd tack that n-niaiiu'd for two years in tlic liroiiclius of 
 a woman of S- years. Removed by oral l)ronchoscopy (Author's case). 
 
 .Mrs. J., aged ')2 years, referred by Dr. j, J. Richardson. Two years 
 previously patient had choked on a tack. For a time there were no symp- 
 toms, then chronic bronchitis supervened, followed ever since by irreg- 
 ular fever and chilliness. Occasional expectoration of blood. Repeated 
 radiography failed to reveal the tack, until a week before admission, 
 when the radiograph (Fig. l*o) was made. Dr. .\. H. Clark reported: 
 "I'reathing diminished throughout right chest, marked at base in front, 
 almost absent at base in back. Marked auscultatory signs of bronchitis 
 on right, moderate on left." .\t the T'resbyterian Hospital the author 
 at oral bronchoscopy luider ether anesthesia found the right inferior lobe 
 bronchus below the orifice of the middle lobe bronchus occluded with a 
 fungating bleeding mass of granulation tissue. Quite free bleeding fol- 
 lowed excision of this. After al)out seventy minutes of work all of the 
 granulation tissue was removed and a dr\ Ik-id was obtaineil. Careful 
 search over this field revealed on the |)osterior wall a small spot where a 
 granulation bud had been nipjied olT at the orifice of a dorsal branch 
 bronchus. In the center of the red s]jot was a black spol which i)roved 
 to l;(.' ilu' point ol the tack. The side-curxed forcejjs were insiiuiated
 
 no 
 
 FOREIGN BODIES IN BRONCHI FOR PROUINGED PERIODS. 
 
 into the bronchial orifice and the intruder withdrawn by a firm grip of 
 the point of the tack (Fig. 188). There was expectoration of blood for 
 a week. The temperature continued to rise occasionally but in about a 
 month came permanently to normal, the cough and expectoration ceased 
 in about three months and now, after almost two years, the patient 
 is reported by Dr. Richardson to be in perfect health. 
 
 Fig, l8y. — Radioyraijh uf Mrs. Is.., showing left pyopucumuthurax wliich was 
 due to the bursting into the pleura of a foreign body abscess of the lung in a 
 woman of 48 years. Collar button was in the lung b\it did not show through pus 
 shadow (Author's case). 
 
 Glass collar button in left bronchus for tzvcnty-six years. Removed 
 by oral bronchoscopy -vithout anesthesia, general or local. Mrs. K., 
 aged 48 years, was admitted to the Presbyterian Hospital with a history 
 of having "swallowed" a pearl collar button twenty-six years previously. 
 There was some cough and bloody expectoration at the time of the acci- 
 dent and for about a year subsequently. This was before the discoveries
 
 FOKKICX r.oDIKS I.N ItKdXCllI l-UK i'UOUIXGED PKRIODS. 
 
 HU 
 
 of bronchoscopy and roentgenoscopy. Xo further puhnonary symptoms 
 were noted for twenty-four years. During the twenty-fifth year there was 
 an attack of "jjueumonia" in treating which the attending physician (a 
 \ery competent man i ridiculed the patient's idea that the button could 
 still be in the lungs. In the early part of the twenty-sixth year, under 
 the care of a third plusician. a second attack of pneumonia occurred. 
 
 Fic. Kjo. — Kadiij.L;r.i|ili ol M i >. K., aiur istcrnal drainage of llic abscess by 
 Ur. J. Hartley Anderson. Foreign body (collar l)Utton) present did not show. 
 The dark line I'rom the first rib downward and outward toward the drainage tube 
 is the thickened visceral pleura seen on edge. The hing is collapsed as far as the 
 pleural adhesions will permit. 
 
 followed 1)\ jiain in the left >idc. bloody, foul expectoration, lever and 
 emaciation. Again the patient's story of the collar button was ridiculed. 
 Extremely feeble and emaciated, she fell into the hands of Drs. Thomas 
 I.. Ray and S. H. I'ierce who, on the ])h_\sical signs, made a diagnosis of 
 lung abscess and i)yopneuniotliorax. Suspecting foreign body origin, 
 they referred the case to the author.
 
 312 
 
 FOREIGN BODIES IN BRONCHI FOR PROLONGED PERIDDS 
 
 On admission to the l^rcsbyterian Hospital, the woman's tempera- 
 ture was 102°, pulse 1-10, respirations 4U. Sputum was profuse, thick, 
 foul and of dark gray color. A radiograph (Fig. ISii) by Drs. Johnston 
 and Grier showed a dense shadow over the left lung, which they believed 
 to be pus. Dr. John W. Boyce corroborated Dr. Pierce's findings and 
 urged immediate drainage of the pleura h\ rib resection and a wide open- 
 
 FiG. 191. — Quartering lateral radiograph by Dr. Gcurgc C. Johnston showing 
 collar bntton in tl.e lung between the heart and the spine. (Same patient as Fig. 
 190). 
 
 ing. This was done by Dr. J. Hartle\' Anderson, evacuating over a quart 
 of putrid pus, Drs. Johnston and Grier then made another antero-jios- 
 terior radiograph (Fig. IDO) which showed that the ])us was well drained, 
 but did not show a foreign body. In further search they made a diagonal 
 radiograi)h (Fig. 1!)1 ) which showed a collar button between the heart 
 and the spine, in direct line with the stem bronchus of the left side. Dr. 
 Johnston stated that there was tissue overlying the foreign body and that
 
 FOKHIGN BODIKS IN BRONCHI FOR PROLONGICD PERIODS. 313 
 
 in order to reach the foreign body it would be necessary to remove this 
 tissue in a direct Hue witli the axis of the stem bronchus. W'itli the 
 assistance of Drs. Patterson, McCready and AIcKee, without anesthesia, 
 general or local. I passed a bronchoscope through the mouth and found 
 the inferior lobe bronchus occluded just below the orifice of the upper 
 lobe bronchus by a cicatricial mass containing three apertures through 
 which reddish granulations, that bled when wiped, w-ere protruding. Clear- 
 ly, dilatation, as practiced in previous cases, was useless and, with the 
 accurate localization and advice of Dr. Johnston as a guide, the author 
 excised tissue endoscopically with biting forceps until a rather large cav- 
 ity full of granulations was reached. Excising the granulations and wip- 
 ing away blood, foul pus and secretions, the collar button (Fig. 192) 
 came into view bedded in granulation tissue, from which it was readily 
 removed through the mouth along with the bronchoscope and forceps. 
 The foul odor disappeared in about four weeks, cough and expectoration 
 lessened, and both ha\e now disa[)peared. The hmg has completely filled 
 
 ■<<jedj^P 
 
 Fic. ig2. — Glass collar button rcmoxed from the lung of Mrs. K. by oral 
 bronchoscopy without any anesthesia, general or local. It had been in the lung 
 for twenty-six years. 
 
 with air as shown radiographically. The external pleural fistula per- 
 sisted for a number of months, but healed completely and now, one and 
 one-half years later, Dr. Pierce reports the patient to be in perfect health 
 and weighing IT.") pounds. 
 
 The ]Kjints of special interest are: — 
 
 1. The extremely long sojourn of the foreign body in the lung; the 
 longest, to the author's knowledge, yet recorded. 
 
 2. The freedom from symptoms after the first year, for so long a 
 ]ieriod, twenty-four years. This is exceptional. 
 
 ;{. The bursting of a foreign body abscess into the pleura, while 
 doubtless not of tiie greatest rarity of occurrence, has been recorded in 
 only a few instances. 
 
 I. The foreign iiody did not fdlldw the discharging aiiscess into 
 the pleura! ca\ ity. 
 
 •">. The necessity of the most exjiert ray work. It was only the 
 t|uartering lateral radiograjih that could show this foreign body, and all 
 ordinary work would iia\e been negative. Good lateral radiographs are 
 exceedingly dilfK-idt t(i make nf adult subjects.
 
 314 FORIUGN BODIES IN BRONCHI FOR PROLONGED PKRIODS. 
 
 (5. The necessity in such cases of draining pus collections in order 
 to get a radiograph of a foreign body, which would not show through the 
 purulent shadow. 
 
 7. The feasibility of endoscopically removing a tissue barrier in 
 order to reach an ab.scess cavity in the lung, when guided by both an 
 accurate radiographic localization and ocular evidence through the tube 
 that the tissue to be removed is pathologic. 
 
 8. The advantage of working without an anesthetic. This patient 
 was in extremis and an anesthetic was not to be thought of. Moreover, 
 the peroral bronchoscopy was no more painful than the filling of a sensi- 
 tive tooth cavity, for which no one re(|uires an anesthetic. The air pas- 
 sages were full of pus mixed with blood from the granulations. The 
 
 Fig. 193. — Enlarged view of fingers from a pliotograpli i>i liands of Edward 
 M., showing "clubbing" of the linger ends. (Author's case). Photographed by 
 Dr. H. H. Fischer. 
 
 coughing of the unanesthetized patient greatly assisted in remo\ing this 
 by the ''sponge pumping" method. 
 
 Nail in left bronclnis four years. Remoi'cd by oral hronclioseopy 
 'ivithotit anesthesia, (je)icral or local. Edward AI., aged ten years, re- 
 ferred by Dr. Robert L,. Morehead, of New York City. Four years 
 previously the child, then six years old, aspirated a nail, followed by 
 paroxysms of coughing and gradually failing health. Sputum examina- 
 tion negative as to tubercle bacilli. Mixed pus cocci and saprophytes 
 were present. Dr. H. T. Price reported the results of his physical e.x- 
 amination as follows : 
 
 Child fairly well developed, rather languid, color good, head large, 
 fingers markedly clubbed (Fig. 1!)3), toes not so large, slight cough at 
 intervals of half to two minutes. Breath very offensive after cough-
 
 FORKICN liODIK.S I\ r,R(t.\CUI FOR PROLONGED PKRIUDS. 
 
 ■M-) 
 
 ing, especially if a paro.\_\sni occurs. Pigeon breast, rather emaciated 
 chest, indrawn on left side (Fig. 194). Apex beat tumultuous in sixth 
 interspace and about one inch to left of nipple line. Heart much en- 
 larged to left barely comjiensating with a mitral regurgitaliun trans- 
 mitted to left and all over left side and back. Jugular j)ulsati(jn. Child 
 camiot lie with comfort on account of posture causing coughing sf)ells, 
 
 Fig. 194. — I'liotciHrapli "f Edward M., aged ten years, who for four years 
 had a nail in a dorsal brancli of the posterior lobe bronchus. Note emaciation, 
 "pigeon breast," indrawn on left side, clubbed fin^jers. (Author's case. Photo- 
 graphed by Dr. H. H. Fischer.) 
 
 nor can he lean forward without distress. Right lung negative as to 
 dullness, ncjrmal breathing, but few rales on deep respiration. Left 
 chest dull all o\er. \'ery little air entering upper lobes. A few rales 
 on di'cp inspiration. Lower lobe, breathing of bronchial ty[ic witii large 
 moist rales, suggesting cavity, about ninth rib and two inches Irom 
 spine. Abdomen negative.
 
 316 FOREIGN BODIES IN BRONCHI FOR PROLONGED PERIODS. 
 
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 FORKIGN P.ODIKS I.N liKONClII l-dK rROLOXGKD PERIODS. 317 
 
 Radiographs taken in lirooklyn showed Ihe nail in the center of a 
 large shadow that iiickided nearly all of the left lung (Fig. 195). At 
 the Presbyterian Hospital the author passed a bronchoscope and encoun- 
 tered a large quantity of very foul pus. After removal of this and the 
 excision of granulations the nail was found in a large cavity. There 
 was no stricture and the removal presented no particular difficulty. The 
 child returned to Xew VorU the next evening. Dr. Moorehead reported 
 later that the child did well for three weeks, his condition was improved, 
 and his cough and expectoration very greatly diminished. Suddenly 
 about a month after the nail was removed, he had a convulsion and on 
 the following day, two more. Complete paralysis of the left arm, left leg 
 and left side of the face developed and he died five days after the initial 
 
 Frc. 196. — Drawinii of nail removed from lung oi Edward M. by oral bron- 
 choscopy without anesthesia, general or local. 
 
 convulsion. .A conMillant neurcjlogist stated that it was undoubtedly a 
 case of embolism of the middle cereljral artery. Xo autopsy was per- 
 mitted. 
 
 Remarks. This case shows clearly that removal of the foreign body 
 cannot be expected always to be followed by recovery in a case with an 
 extensive \irulent pus focus in the lung. The emaciated wretched con- 
 dition of the child shows the havoc that can be wrought by a foreign 
 body in the lung. The close simulation of tuberculosis might be very 
 misleading in case of a foreign body not radiographically \isible. The 
 source of the embolus might have been the lung or the heart. Occur- 
 ring over three weeks after bronchoscopy it could have had no relation 
 thereto.
 
 CHAPTER XVII. 
 
 Unsuccessful Cases of Bronchoscopy for 
 Foreign Bodies.* 
 
 After a monotonously long series of successful cases, the bronchos- 
 copist is apt to think there are no limits to bronchoscopic foreign body 
 removals. Sooner or later, however, he will discover that there are very 
 decided limitations. These limitations so far as present experience shows, 
 are all the failure to find a small body that has entered a minute bronchus 
 far down and far out toward the perijihery. In such cases, the localiza- 
 tion methods of the author's films, Boyce calipers, fluoroscopy, etc., 
 having failed, the question arises whether it is advisable to incur the risk 
 of endoscopic excision, with the aid of two fluoroscopes, one for the 
 lateral and another for the vertical plane. Xaturallv the risk of such a 
 procedure will depend upon the nature of the tissue inter\ening between 
 the foreign body and the end of the bronchoscope, and this, in turn, will 
 depend upon the location of the intruder. With foreign bodies in the 
 larger bronchi near the root of the lung, it is not to be thought of, but 
 here endoscopy is rarely, if ever, unsuccessful. At the extreme periph- 
 ery of the lung the danger is less, and is largely concerned with the 
 contingency of opening a vessel that will permit blood to be retained to 
 break down later, as well as the immediate risk of hemorrhage. The 
 author has planned such an operation but has not yet encountered an 
 endoscopically unsuccessful case of foreign body so located that the 
 endoscopic operation seemed to involve less hazard than thoracotomy. 
 
 Theoretically, it might be supposed that the shortening of the bron- 
 chi that takes place in pneumothorax might be sufficient to cause the 
 point of a pin to emerge from the invaded bronchus into the larger one 
 of which it is a branch. In one of the author's cases (Miss J.), this did 
 not occur. (Compare Figs, liiii and 200.) The question arises, what 
 shall be done if the bronchosco])ist fails to find the foreign bodv after 
 having used all the methods of localization mentioned? The writer 
 
 ♦Revised from author's p,Tper read before the American Larynsrolosical .\s.so- 
 ciation. May, 1914.
 
 UNSUCCESSFUL CASKS OF BRONCHOSCOPV. I?!!) 
 
 feels that duty to a felhjw creature demands that at least one other 
 skillful hronchoscopist should try before deciding upon either leaving 
 the foreign body alone to nature, or sending the patient to the general 
 surgeon for thoracotomy. Up to the present writing, the author has 
 had five failures and he congratulates himself upon his not having 
 advised either of these alternatives without the patient having the bene- 
 fit of the efiforts of another bronchoscopist. In his first failure. Prof. 
 Killian had previously failed, and the author had with him at the time 
 of his own attempt, Algernon Coolidge, Jr.. who made a careful search 
 at the author's request after the author's failure to find the foreign body. 
 In the second case, Cornelius Coakley had previously attempted to find 
 the foreign body. In the third case, Samuel Iglauer and J. W. Murphy 
 had both attempted to find the foreign body, and in the fourth case. Dr. 
 P. M. Hickey had attempted to find the foreign body. In the additional 
 case the i^atient was taken away from the hospital by the father, who 
 positively refused to leave it until another bronchoscopist could be called. 
 In the four cases enumerated, after the eitorts of the expert bronchos- 
 copists mentioned had failed to find the foreign body, the author felt 
 that, with his own eft'orts failing also, the patient had been given the bene- 
 fit of everything that bronchoscopy had to oft'er, and it remained to con- 
 sider the next step. 
 
 hi deciding this (|UCstion, it is first necessary to consider what will 
 hap])eii if the foreign body is allowed to remain. This has been gone 
 over analytically by Delavan. Roe, Wood and others in the pre-bronchos- 
 copic days and bv Clayton, Clark and Marine more recently, as else- 
 where mentioned. liecausc of its brilliant achievements, bronchoscopy 
 has been universally accepted, and for that reason, but very few foreign 
 bodies have remained in the bronchi when their presence was known. 
 Th.e cases where bronchoscop\- has failed have been limited to cases in 
 which the foreign body could not be foiuid. and these have invariably 
 been very small bodies far down and far out at the periphery. In this 
 location, the most jirobable result is that an abscess will form and that 
 it will burst through into the pleural cavity. It then becomes a question 
 whether thoracotomy shall be done at once upon the failure of bronchos- 
 copy or whether the abscess formation with invasion of the pleura shall 
 he av.'aitcd. The chief arguments against waiting are that the patient 
 may not survive sufficiently long for the development of the abscess and 
 the reaching of the pleura. Furthermore, the foreign body may not 
 follow the abscess into the pleural cavity as seen in the case of Mrs. K., 
 rejjorted in a jirevious chapter. In that instance the foreign bod\- was 
 easilv removed through the nKJUlh because it was large and consequently 
 easy to find. Because of its large size, also, it had not reached the ])oint
 
 320 UNSUCCESSFUL CASES OF BRONCHOSCOPY. 
 
 near the periphery after the original accident, and it took twenty-six 
 years for the abscess to reach the pleura. During the wait for an ab- 
 scess to reach the pleural cavit\', there is. of course, the possibility that 
 the foreign body may slough loose and be coughed out. Such a possibil- 
 ity is remote in any case and in case of some bodies, as pins, it is impossi- 
 ble. Furthermore. ( Delavan. IJib. ]ii7 ) lesions may be established which 
 will result in the death of the patient even after the foreign body has 
 been gotten rid of. (See case of Edward M., in Chapter X\'I). Na- 
 ture can cure appendicitis and can amputate a limb, but no one know- 
 ingly takes the risk of waiting. Apropos of this, a very interesting col- 
 lection of thirty-two cases is reported by Clarke and Marine, in which 
 gang'-ene of the lung followed the aspiration of a foreign body. Their 
 analysis is as follows: "Of thirty-one cases, the foreign body was a tooth 
 twice, a pin once, a piece of wood once, a button twice, a head of grain 
 or grass seven times, a bit of evergreen twice, a fruit stone twice, a bone 
 ten limes : not mentioned, four times : that it occurretl with ei|ual freque:ic\ 
 in adults and children ; that it remained in the bronchus before gangrene 
 set in from four days to five months, usually under three weeks. Gan- 
 grenous process lasted from three days to four years, most frequently 
 from two to four weeks : the outcome was death in twenty-one cases, 
 reco\ery after thoracotom\- in two, and spontaneous recover\^ in four 
 cases. The foreign body was coughed up in five cases, four of which 
 subsequently died and only one recovered." To these statistics is to be 
 added the case that Clarke and ^Marine themselves observed, in which a 
 man died of pulmonary gangrene seventeen days after aspirating a frag- 
 ment of bone, death occurring two days after the first appearance of 
 putrid expectoration, \iewing the question impartially from all sides, 
 the author believes, first, that large foreign bodies, which necessarily 
 stop in the trachea or larger bronchi, can always be removed by bron- 
 choscopy, therefore, thoracotomy is absolutely out of consideration. In 
 case of small foreign bodies far down and far out at the periphery, after 
 two expert bronchoscopists have failed to find the foreign body, the in- 
 truder should be removed by external operation, and the sooner after the 
 bronchoscopic failure, the better, because of the usually early develop- 
 me:it of septic processes around an aspirated foreign bod\-. .Modern 
 de\elopments and especia!l\' the intratracheal insufflation anesthesia, 
 originated by IVIeltzer and Auer, and developed by Elsberg, Janewav and 
 others. ha\e ])laced thoracotomy on a plane never before obtained, and 
 while the pleural shock remains, the mortality is very much decreased and 
 the operation has reached the stage where it is justly entitled to con- 
 sideration in cases where two expert lironchoscopists have failed. It is 
 certainly preferable to taking the chances of lea\ing the foreign body
 
 UNSUCCESSITL CASES 01* BRONCHOSCOPY. 321 
 
 alone. Formerly, there was great difficulty in finding the foreign body 
 after the lung was open, but in the modern oiieration with the very large 
 flap and ample opening, where the entire lung can Ije handled, the 
 chances of not being able to find the foreign body are very small. In 
 the event of a foreign liodv reaching the ])leura either with or without 
 pus. it should be immediately removed by pleuroscopy (q.v. ) or by 
 thoracotomy, without waiting for adhesive pleuritis. 
 
 As to the details of thoracotomy, the author has never done the 
 operation and ne\er will. Me l)egs. however, to make four stiggestions. 
 1. Tn these days of insulilation intratracheal anesthesia, the bronchos- 
 copist is of no use in the operation. .\nv aid in localization he may 
 be able to afford is better given verbally bv naming the approximate 
 location of the invaded bronchus. 2. The best method of visceral localiza- 
 tion is by the author's transparent films, because after collapse of the 
 lung, the relation of the visceral to the bony anatomy is entirely changed. 
 To know the bronchus invaded simplifies the search. 3. The best method 
 of location of the osteoplastic flap is by the method of Lewis Gregory 
 Cole and other expert radiographers. 4. As the infective risk is slight, 
 and the ojjcrative risk is greater than the s(|tiare of the duration of the 
 operation, the thoracotomy, especially in children, should be done without 
 gloves. However trained the gloved touch, no one can argue that a i)in 
 cannot be found c|uicker in the lung without gloves than with them, espe- 
 cially in the case of infants and children where the largest possible open- 
 ing will not permit the use of llie whole hand. Extraordinary care in 
 preparation of the han<U will make the hands reasonabh' safe from in- 
 fecti\e risk in this, the niily iipi-r.'ition in surgery where gloves ma\ kill 
 the i)atient 
 
 THK ArTUOU's UNSUCCESSFUL CASES. 
 
 Of the author's five unsuccessful cases, one was before the dcvel- 
 oi)ment of bronchoscopy to a reasonable degree of efficiency, and four 
 cases have occurred since. All were failures to find a small foreign bo(l\- 
 in a minute bronchus tar down and far out toward the peripherv. The 
 author li()i)es that his el.sewhere mentioned, recently perfected means of 
 localization will in the future be of assistance in lessening the number 
 .if inilindalile foreign bodies, though these methods were used in the last 
 case of the four and failed to enalde success. In each of these four 
 cases removal had been j)reviously attempted by skillful bronchoscopists 
 of large ex|)erience. Had the .luthor .done failed on these four cases 
 he woulfl feel that they were personal failures. On the contrary they 
 should be cf)nsidercd as failures of brouchoscopy and should be analyzed 
 as such in order that br()ncho>co])\ . like ;uiy other de])artment of medi- 
 cal science, shall profit li\ its f;iilures.
 
 322 
 
 UNSUCCESSFUL CASES OF BRONCHOSCOPY. 
 
 Fig. 197. — Radiograph of pin in right hing of a girl, aged eighteen years. 
 The pin could not be toimd at bmnchoscopy. (Mis? C). Lower radiograph 
 shows how the pin had migrated towards the pleura at the end of two years.
 
 UNSUCCESSFUL CASES OF BKONCIIOSCOPV. 
 
 323 
 
 FiK. Kjy.— Kailiograplis, anUT"i)nsicrii)r ami latiral (I'y l*r, l.angc ul Cincin- 
 nati) showing pin in posterior t)rani.-h of left inferior lobe hronclnis of Miss J. 
 The |]in is rctoudied for clearness.
 
 324 
 
 UNSUCCESSFUL CASES OF BRONCHOSCOPY. 
 
 Aliss C, aged eighteen years, referred by Dr. Edward S. Bacon. 
 Patient had aspirated a pin four weeks previously. No cough, expectora- 
 tion or other symptoms. Dr. Bacon saw the pin endoscopically in the 
 right bronchus immediately after the accident, but was unable to dis- 
 impact it with all the traction he deemed safe. A few weeks later the 
 pin was, radiographically, found to have gradually worked its way to- 
 ward the periphery of the lung. P^rof. KiUian, who was the guest of 
 the American Laryngological Association at the time, made an unsuc- 
 cessful bronchoscopic attempt at removal. A few weeks later the author 
 passed a bronchoscope. Ether was used at the start, but was discontinued 
 after about fifteen minutes. The author was honored by the presence of 
 
 Fig. 198. — Radiograph of Mrs. S. showing pin in posterior branch of inferior 
 lobe bronchus. Pin could not be found at bronchoscopy. (Retouched for clear- 
 ness). 
 
 Algernon Coolidge, ]r., one of the pioneer bronchoscoi)ists. Neither of 
 US could find the pin which was plainly exidcnt in the radiograph (Fig. 
 in;). \\'e found the bronchi of the left lung all normal in appearance. 
 The mucosa of all the right bronchi was congested and swollen. The 
 orifices of the branch hnjnchi were diminished to about half tlie normal 
 size, as estimated by comi)arison with the opposite side. As Dr. Coolidge 
 pointed out, there were no localizing signs, such as emerging pus, to lead 
 one to suspect one bronchus more than another. A few were care- 
 fully explored by the author with negative results. The search occupied 
 about an hour and a half. There was no reaction and the patient left 
 the hospital. Her health was fair at the end of a year. Occasional "jag-
 
 UNSl'CCESSI-UL CASIiS Dl'' BRONCHOSCOry. 
 
 335 
 
 ging" pains were felt and there was some cough. At the last rejiort 
 the pin was gradually working toward the pleura. 
 
 Mrs. S., aged forty-three years. Seen in consultation with Dr. 
 Cornelius Coakley, at St. Luke's Hospital, New York City. Patient 
 had a strumic stenosis for which a tracheotomy had been done by Dr. 
 Far(|uar Curtis. A pin had been aspirated into the bronchus two 
 months before admission, and the excellent radiographic work of the 
 
 Fig 200. — Radiograph showing displacement of pin after pneumothorax. (Case 
 of Miss J). Ketoiiclied for clearness. (Author's case). 
 
 hospital radiograjihcr had located the pin |ioslcri(jrly very low in tlie 
 left lung iTMg. 1!!S). 13r. Coakley had made a careful and skillful 
 search without finding the ])in. The author was e(|iially unsticccssfiil. 
 There were no localizing signs. In one of the bronchi the author thought 
 he felt contact nf the pin but it conld nut be suflicientlv conlirnicd to 
 justify using the f(:rcci:s. The jiaticnt died one and one-half years 
 later, after refusing external operation for pulmonary abscess.
 
 326 
 
 UNSUCCESSFUL CASES OF BRONCHOSCOPY. 
 
 Remarks. In passing, it may be said that tlie extreme posterior loca- 
 tion of the pin and the presence of a tracheotomic wotmd ( made for 
 strumic stenosis ) led the author thoroughly to test out the supposed ad- 
 vantages of tracheotomic or '"lower bronchoscopy." He could discover 
 no advantage whatever as compared to oral bronchoscopy with the head 
 in the Boyce position. This was in 1908 and the author has not done a 
 tracheotomic bronchoscopy for a foreign body since. 
 
 ]\Iiss J., aged nineteen years, referred by Dr. Samuel Iglauer for a 
 pin in a posterior branch of the left inferior lobe bronchus as shown by 
 an excellent radiograph (Fig. 1!);)) by Dr. Lange, of Cincinnati. (See 
 report of Dr. Iglauer, Bib. 221.) Drs. Iglauer, Mithoefer and J. W. 
 Murphy, all endoscopists of large experience, had failed to find the pin 
 
 Fig. 201. — Radiugrapli shu\vin,u a pin almost at tlic pt-riplKTy of \\k lung of a 
 child of i6 months. (Author's case). 
 
 bronchoscopically. The author made two bronchoscopic searches, one 
 with ether and one without. He could not find the pin nor any pathologic 
 signs of its presence. Twenty-four hours later pneumothorax was evi- 
 dent. The pin was displaced and tilted as shown in Fig. 200. Another 
 search was made but it was also unsuccessful. Dr. J. Hartley Ander- 
 son removed the pin by thoracotomy, making a large osteoplastic flap 
 posteriorly. The patient made a good recovery and in a few weeks the 
 lung had expanded. 
 
 Carol H.. aged sixteen months, referred to the author by Dr. P. ]M. 
 Hickey, for a ]iin in a dorsal branch of the left inferior lobe bronchus 
 (Fig. •?oii). Two bronchoscopies by Dr. Hickey had failed to find the 
 [lin and the autlior was equally unsuccessful. .\ general surgeon, by a 
 ([uick and skillful thoracotomy, removed the pin. 'J"he ]iatient succumbed 
 twentv-four hours later.
 
 UNSUCCKSSFUL CASKS OV HROXCHOSCOPV. 337 
 
 After the foregoing was written and while this book is in press the 
 author has had another unsuccessful case. Drs. Henry Janeway, Harmon 
 Smith and Sidney Yankauer had failed to find a metallic foreign body 
 which showed plainly in excellent lateral and anteroposterior radiographs 
 (by Dr. A. S. Holding ) and they honored the author by calling him to the 
 case. Bronchoscopy by the author at the New York General Memorial 
 Hospital was equally unsuccessful in seeing the foreign body. Dr. A. S. 
 Holding fluoroscopically saw the intruder upward and outward and for- 
 ward from the bronchoscopic tube-mouth when the latter was in the left 
 upper-lobe bronchus, thus definitely locating the foreign body in an an- 
 teriorly ascending branch of tlie left ui>per-lobe bronchus. A subsequent 
 thoracotomy confirmed the localization ; liut the patient succumbed. 
 
 From this case it is fair to conclude that a foreign body may get so 
 far toward the periphery in the upper lobe-bronchus as to be beyond the 
 limitations of bronchoscopy. (Hit of six upper lobe-bronchus cases, in 
 the author's experience, this is the only one that invaded so far as to be 
 beyond reach.
 
 CHAPTER XVIII. 
 
 Foreign Bodies in the Esophagus. 
 
 Part of this subject was consitlered in a previous chapter (XII) on 
 the general subject of foreign bodies in the air and food passages. A 
 number of important points require additional consideration. 
 
 Etiology. In the esophagus the lodgment of foreign bodies is in- 
 fluenced by five factors. 
 
 J. The shape of the foreign body (pointed, rough, etc.). 
 
 ;!. Resiliency of the foreign body (safety pins, etc.). 
 
 3. The size of the foreign body (a large meat bolus). 
 
 L Narrowing of the esophagus, spasmodic or organic, normal or 
 pathologic. 
 
 5. Paralysis of the normal esophageal propulsory meclianism. 
 
 The modes of action of the foregoing list of causes are self-evident, 
 but numbers three and five require further consideration. As a rule, 
 when ordinary food lodges in the esophagus, there is a strong suspicion 
 that there is some organic trouble present, such as compression by an 
 aneurysm, or a malignant, or a cicatricial or a spasmodic narrowing. 
 In one of the author's cases a deckhand, eating a very hurried meal, 
 had an enormous Ijohis of meat lodge in the esophagus at the crossing of 
 the left bronchus, completely occluding the gullet. The pyriform sinuses 
 were full of secretions and a large quantity of secretions was brought 
 through the aspirator before the esophagoscope reached the bolus at the 
 crossing of the left bronchus. After the esophagoscopic removal of the 
 meat, the esophagus seemed normal and free from compression or 
 stricture. The man had never had any trouble in swallowing before, 
 and has had none since, although three years have elapsed. It seems 
 quite evident that it was only the enormous size of the bolus which 
 caused it to lodge, and it is probable that it passed the cervical narrow- 
 ing in more or less elongated form but broadened out as it reached the 
 thoracic esophagus, during the negative i)ressure of an inspiration, and 
 in this more expanded form, it completely occluded the narrowing at 
 the crossing of the bronchus. Paralysis of the esophagus, at first
 
 FoKKIGN BODIES IN THE ESOPHAGUS. 
 
 32!) 
 
 thought, might be thought not to interfere with the downward passage 
 of any substance and yet even liquids will not go down a paralyzed esoph- 
 agus as mentionLMi under diseases of the esophagus.* 
 
 Why do foreign bodies in the esofrhagiis lodge most frequently at 
 certain localities? As in the air passages, the greater frequency of 
 lodgment of foreign bodies in certain localities is governed by factors 
 which mav be classed in three main divisions: 
 
 ]. (a) The size and shape of the foreign body, whether long, broad, 
 
 Fig. 202. — Schematic illustration of the site of lodgment in 135 cases of for- 
 eign body in the esophagus, from statistics collected from litirature by H. Burger. 
 Th., thyroid cartilage. Cr., cricoid cartilage. M., manubrium. Cohnnn A shows 
 the location in those cases where relation to the spine was mentioned. Column B 
 shows the position of the intruder when this was given in relation to the thyroid, 
 cricoid, manubrium or sternum. In column C are indicated the cases wdiere the 
 localization was given in more general terms. (After Sir St. Clair Thomson). 
 
 pointed, angular, disk-like, etc. ( b) Its surface, whether rougli or smooth, 
 (c) Its i)hysical prii]ierlies, resiliency, ])lasticity, absorbtivity, etc. 
 
 2. Tlie anatomic peculiarities of the various localities, (a) Angles, 
 arcs, (b) Fixed and moliU- narrowings. 
 
 3. Paralysis of the eso])hageal i)ropulsory mechanism. 
 
 An interesting tabulation f)f reported cases of eso])hageallv loiigcd 
 foreign bodies is shown schematicallv in I'ig. 'i^^'i, winch is rc|>r(iiluced 
 
 •Aei' as an etiolosric fuctor i.s .shown by the fact that of the iiulhor's 4;) cases 
 of bones in the e.«ophngu8 aU but 2 were in adult.s; wheien.-;, of 38 cases of 
 esophaKcally Iodised coin.-;, in thi- iiuthor'.s experience, jill were In children.
 
 330 FOREIGN BODIES IN THE ESOPHAGUS. 
 
 from Sir St. Clair Thomson's excellent book. Of course, a considerable 
 latitude for inaccuracy must be allowed, because of the necessarily inac- 
 curate localization in perhaps the majority of published reports. Never- 
 theless the grouping of almost all of the cases in the upper third of the 
 esophagus is very striking and coincides with the experience of all 
 esophagoscopists. Most of the very few cases of lower lodgment en- 
 countered have been pushed down by blind methods. \'arious reasons 
 have been assigned for the lodgment of almost all foreign bodies in the 
 upper third ; but none of them appeal to the author as being satisfactory. 
 His own opinion is that it is a physiological narrowing due partly to 
 spasm, but mainly to the fact that the cervical esophagus is normally 
 collapsed and is not subject to the negative pressure that expands the 
 intrathoracic portion of the esophagus. Xot only is the musculature of 
 the cervical esophagus more powerful in its contractions, but it is a col- 
 lapsed tube. The mediastinal esophagxis, on the contrary, is being 
 pulled open and thus the foreign bodies, unless of verj- large size, are 
 relieved and readily find their way downward. Against the theory that 
 it is simply the quiescent narrowness of the cervical esophagus that 
 holds the foreign body, is the fact that there is plenty of room for quite 
 a large esophagoscope to override the foreign body and pass it without 
 the inexperienced operator being able to see the foreign body at all. If 
 the esophagus were narrow at the point and retaining the foreign body 
 only by tiie smallness of its lumen, one would suppose this overriding 
 could not occur. ( )ne point that indicates that there is a large element 
 of spasm in the lodgment of foreign bodies in the esophagus, is the fact 
 that operators who use general anesthesia have a much larger propor- 
 tion of foreign bodies escape downward than those who do not. Since 
 abandoning anesthesia for the removal of esophageally lodged foreign 
 bodies (except in the case of very large bodies) the author has not had 
 a single case of escape of the intruder downwards during esophagoscopy. 
 From esophagoscopic observation in other than foreign body cases one 
 would suppose that foreign bodies would lodge in the clutch of the crico- 
 pharyngeus but, in the author's experience, this is not nearly so frequent 
 a locality as the upper thoracic aperture. We may conclude, then, that 
 it is the physiological narrowing at the upper thoracic aperture. This 
 narrowing disappears under anesthesia in the recumbent position and 
 is not demonstrable by cadaveric anatomy ; hence, probably is partly 
 muscular and partly the crowding of the adjacent viscera into the fixed 
 and narrow upper thoracic aperture. It is probable that the anatomic 
 changes associated with the phylogenetically late upright posture of man 
 is associated with the physiological narrowing which causes foreign 
 bodies to lodge at the upper thoracic aperture.
 
 1-OKEIGN BdDIKS IN THE ESOPHAGUS. 
 
 331 
 
 Syinf'tonis of forc'ujn body in the esophagus, and indications for 
 esophoi/oscopy. It would be a waste of valuable space extensively to 
 consider here the symptoms of esophagealh' lodged foreign bodies. They 
 form no basis for the determination as to whether an esophagoscopy 
 should he done or not. for symptoms may be entirely absent, even in 
 cases of rather large intruders. If the patient has swallowed a foreign 
 body, that body must be found in the anatomy or in the stools. A very 
 small foreign body may cause regurgitation and complete inability to 
 swallow even water. This occlusion may be due to spasm, swelling of the 
 
 Fig. 20,^. — Lateral r;'.(linj;raph sliowins lodgment of a collar Inittoti in the 
 esophagus at the usual location, at the upper thoracic aperture — not at the crico- 
 pharyngcal narrowing. Locatiim corroborated at esophagoscopy. (Author's case). 
 
 esophageal walls, or to augmentation of the size of the intruder by ex- 
 pansir)n with absorbed inoisture, or by accumulation of food about the 
 intruder. Coins mav cause intermitlciit occlusion liy change of position. 
 They usually permit food to pass and they often show a bright streak 
 down the center third of one or both sides where the passing food has 
 kept the surface bright, while at the lateral thirds, which are more or 
 less buried in the folds of the mucosa, corrosion or oxidation darkens 
 the coin. This is most noticeable in silver coins, in which the lateral 
 thirds arc darkened by the formation of silver sulphide on the surface. 
 ("See illustrations of coins in case reports in a sulisequent chai)ter.)
 
 332 KORKIGN B<5DIES IN THE ESOPHAGUS. 
 
 This shows that foods pass flat objects like coins quite readily as a 
 rule. Occasionally, however, occlusion is complete from the outset. 
 Carpenter (Bib 73) reports one such case in which nothing could be 
 swallowed in the three days between lodgment and esophagoscopic re- 
 moval. On the other hand a foreign body which has remained long in 
 situ may give rise to no sym])toms whatever and if the lodgment has been 
 in childhood, growth and development may possibly permit the child to 
 swallow sufficiently well that no difficulty is noticeable, as in a case re- 
 ported by W. G. Porter, in which a half -penny had remained in the 
 esophagus of a child for eight years, who then was brought for in- 
 definite gastric symptoms, not for dysphagia. Dyspnea may be a symp- 
 tom of an esophageally lodged foreign body. In one of the author's 
 cases a large foreign body produced so much compression of the trachea 
 that the trachea was explored first and found to be very much stenosed 
 because of the forward pressure on the membranous party wall bv the in- 
 truder. Cough is one of the symptoms of foreign body in the esophagus 
 that must not be forgotten. It may be due to reflex irritation, to se- 
 cretions overflowing into the laryn.x from the occluded esophagus, or to 
 perforation, traumatic or, later, ulcerative, of the party wall causing 
 leakage of food or secretions into the trachea. In one of the author's 
 cases, elsewhere herein reported, the mother said the child "coughed 
 until it vomited." What really happened was the leakage of the nurs- 
 ling's focd thrnugh tlie ulcerative foreign bodv fistula from the esophagus 
 into the trachea resulting in the coughing up of the milk. In foreign 
 body cases in which there is comjilete obstruction the author's symptom 
 of esophageal occlusion may be present. It onsists in the pyriform 
 sinuses, one or both, being filled with secretion as noted on indirect 
 mirror examination in the erect posture. This is, of course, a symptom 
 only of occlusion, not necessarily by a foreign body. It is due to re- 
 tention of fluids which fjtherwise are constantly draining down through 
 the esophagus. 
 
 The localization of the foreign body as to whether it is in the 
 esophagus or in the air passages is considered under the head of bron- 
 choscopy for foreign bodies. 
 
 Prognosis. A foreign body lodged in the esophagus may prove 
 quickly or slowly fatal or may remain for many years if its size, shape 
 and position permit food to pass. E. A. Peters reports the case of a 
 man dying two hours after a tracheotomy done for edema of the glottis, 
 secondary to hemorrhage down along the spine, from the ]iuncture of the 
 jugular vein by a pin swallowed with food. Adelman cites nine cases 
 and Chiari twenty-one cases of perforation of the aorta by foreign bodies 
 in the esophagus. The perforation may be shortly after the lodgment.
 
 I'dUKIGN UODIES KN THE lC.S(jr>H AGUS. 
 
 333 
 
 in the case of sharp bo<Hes, such as pins, needles and sharp bones ; or 
 more slowly by erosion and ulceration. Many cases of foreign bodies in 
 the esophagus have been quickly fatal through perforation and septic 
 mediastinitis. Many others have caused death through suppuration ex- 
 tending to the trachea with consetiuent edema and asphyxia. In cases 
 of [irolonged sojourn of the foreign body in the esophagus thickening 
 
 Fir,. 205. — kadionrapli ol forcis^n body (cuff link) part oi which had ulcerated 
 through from the esophagus into the trachea of a three months old infant. Re- 
 moved partly by oral lironchoscopy and partly by oral esophagoscopy witlunu anes- 
 thesia, general or local. (.Author's case). 
 
 ;nid bypcrpl.'isia of the esophageal wall result from nature's effort to 
 ])rotect the surrounding tissues. Sooner or later, however, if not re- 
 moved, the foreign body causes death. livery large museum has speci- 
 mens of this kind, .nid ibc mcjst fre(|uentl\' seen foreign body is the 
 artificial denture. The foregoing remarks, iiowever, api)ly cliicHy 
 to the i)re-csoi)hagoscoi)ic days. To-day, with the radiograph and the
 
 334 FOREIGN BODIES IN THE ESOPHAGUS. 
 
 esopliagoscope, foreign bodies are discovered and promptly removed. 
 Dr. D. Braden Kyle reports a very remarkable case in which he ver\ 
 skillfully removed an artificial denture that had been in the esophagus for 
 seventeen years (Fig. 2\~>). The patient's condition was very serious, 
 and but for the timely work of Dr. Kyle, the patient would have suc- 
 cumbed. Perforation of the upper esophagus may result in cervical 
 cellulitis of varying degrees of intensity. Abscess may result in any 
 of the surrounding tissues, either from direct infection or from secondary 
 necrosis of the tracheal or laryngeal cartilages from infective perichon- 
 dritis. One such case was referred to the author by Dr. Greenfield Sluder 
 for an opinion. A tooth brush bristle and a bit of necrotic cartilage 
 were discharged from an abscess at the mouth of the esophagus of a 
 physician of about forty years of age, after a number of years of ill 
 health. The fistula is still unhealed. Joseph White (Bib. 573) reports 
 a similar case followed by laryngeal stenosis. Many cases are fata! 
 within a short time from perforation and mediastinal abscess. The 
 author has had two cases in which a foreign body ulcerated through from 
 the esophagus into the trachea. One of these has been reported ( Bib. 
 269). The other one is as follows: 
 
 Cuff link that ulcerated from the esophagus into the trachea. Infant 
 C, aged three months. Referred by Dr. J. A. Sullivan. Parents said 
 child "coughed until it vomited." Dr. Sullivan was about to prescribe 
 for the bronchopneumonia present when the parents said they had 
 missed a cuff link for six weeks before and notwithstanding this in- 
 definite statement and the age of the child (only six months at the 
 time), the doctor sent the patient to Dr. George C. Johnston who found 
 the cuff link radiographically (Fig. 205) and referred the case to the 
 author. As the symjitoms seemed altogether tracheo-bronchial, the 
 author passed a lironchoscope first and found the smaller part of the 
 button in the trachea with the stem passing backward towards the esoph- 
 agus. ^^'ithdrawing the bronchoscope the author passed an esopliago- 
 scope and found the larger part of the button in the esophagus with 
 the stem passing forward toward the trachea. (Jn re-examination with 
 the bronchoscope it was found that the smaller end of the button was 
 loose on the stem. With forceps it was soon twisted ot^' and withdrawn 
 through the glottis w^ith the forceps and bronchoscope. The esophago- 
 scope was introduced into the esophagus and the larger portion of the 
 button with the stem was removed without difficulty (Fig. 206). The 
 tem]3erature which had ranged about 103° before the broncho-esophagos- 
 copy remained about the same for about a week and then slowly and 
 gradually subsided. One year later the child was reported perfectly 
 healthv.
 
 FOREIGN BODIES IN THE ESOPHAGUS. 335 
 
 Remarks. The symptom "cougliing until it vomited" was quite evi- 
 dently due to the leakage of the milk from the esophagus into the trachea, 
 where the cough thus excited expelled the milk from the mouth, while 
 the portion aspirated produced the broncho-pneumonia. Considering 
 the vague history of missing a cuft link, and the age of the child (then 
 only six weeks) the practitioner is to be complimented. 
 
 The prognosis as to esophageal function after cases of prolonged so- 
 journ of foreign bodies is closely related to the length of sojourn. The 
 longer the intruder has been in situ the greater the likelihood of stenosis. 
 In D. Braden Kyle's unique case of seventeen years' duration. Fig. 21"), 
 the stenosis required after-treatment which Dr. Kyle carried out so skill- 
 fully as to get an excellent ultimate result. Prognosis may be made very- 
 grave from ill-ad\ised interference, especially blind bouginage and ex- 
 ternal esophagotomy, as will be cited under treatment. The prognosis 
 after esophagoscopy is excellent as shown by the statistics given in 
 this chapter. 
 
 X 
 
 Fk;. 206. — CufY link shown in Fig. 205. 
 
 Even if the foreign body becomes dislodged and moves downward 
 the patient is not .safe. It may cause intestinal perforation (Fig. 207). 
 So long as the inlrndcr remains in the body the prognosis must be 
 guarded. 
 
 Treatment. If t(ir an\- reason immediate removal is contraindi- 
 cated, bismuth subnitrate should be given dry on the tongue in small 
 doses fre(|uently repeated. It will adhere to denuded surfaces. Calomel 
 may be advantageously added to the first few doses. Removal is the 
 only treatment to be seriously considered. With tiie relatively high 
 mortality from external eso[)hagotomy, it certainly seems as though the 
 operation is rarely if ever justifiable in foreign body cases. Compared 
 to other operations in the neck, it has a very high mortality. Further- 
 more, it has happened more than once that an external esophagotomy 
 done on the strength of a radiograph, has failed to find the foreign body 
 because the latter has passed on downward into the thoracic esophagus, 
 where it cannot be reached otherwise than esophagoscopically, and one 
 such case has been recorded in which the patient died from an external
 
 336 
 
 FOREIGN BODIES IN THE ESOPHAGUS. 
 
 esophagotomy at which the foreign body was not found. In view of 
 these things, those who lia\e had most experience in deaHng with the 
 esophagus regard esophagotomy as unjustifiable until after esophago- 
 scopy has failed, and the author's personal opinion is that any and every 
 foreign body that has gone down through the mouth into the esophagus 
 can be brought back the same way. unless it has already perforated the 
 
 Fk;. 207. — Needle in the intestine. Deatli resulted fmm septic peritonitis fol- 
 lowing perforation. Esophagoscopy was opposed by the family physician when 
 the needle was in the esophagus. The position of the stomach is shown by the 
 bismuth shadow. Laparotomy advised when needle remained in one place in in- 
 testine for 6 days. 
 
 esophageal wall, in which event it is no longer a case of a foreign body- 
 in the esophagus. Furthermore, external esophagotomy recpiires a gen- 
 eral anesthetic, which, because of its relaxation may permit the foreign 
 body to move downward. In contrast to esophagotomy, esophagoscopy 
 does not, as a rule, require general anesthesia, and while it iua\- be oc- 
 casionally found that the foreign body which shows so plainly in the 
 radiograph has moved on downward to a lower position, or even into 
 the stomach itself, no harm has been done. In case of its simply having
 
 I'OKI-.IGN liUUIES IX THE ESOPHAGUS. 337 
 
 moved to a lower position, it is just as readily removed with the esoph- 
 agoscope as if it were at the higher point where originally seen in the 
 radiograph. The most favorahle statistics give a 20 per cent mortality 
 for external esophagotomy in adults. The mortality is still higher in 
 children, in some statistics as high as 4'2 per cent. Comparing such 
 mortality with the two or three per cent mortality in esophagoscopy, 
 the operation of external esophagotomy for foreign bodies has been 
 rightly recommended only after failure of esophagoscopic extraction. 
 Doubtless blind attempts at removal have increased the mortality of 
 both procedures but as it has probably increased them both in the same 
 ratio the relative percentages still hold good. It must be borne in mind, 
 also, as pointed out by John C. DaCosta (Bib. IDl ) the esophagoscope 
 in the hands of the inexperienced may be more dangerous than external 
 esojihagotomy. A recent book on surgery has advised the passage of a 
 i)ougie to determine whether the foreign body is present, and if present 
 to push it down. It should be unnecessary at this late day to warn 
 against blind bouginage in foreign body cases. Citation of a few cases 
 will suffice. < )ne death from j)erforation with the bougie which did not 
 push down a foreign body is rejiorted by Arrowsmith. The patient was 
 moribund on admission and told of the eftorts of a physician to push the 
 foreign body down. Mr. Waggette (Rib. .5(i? ) refers to a case in which 
 a sharp piece of bone was overriden b\- the bougie passed by competent 
 surgeons. If the bougie will thus override the foreign body in the 
 hands of competent surgeons, and in certain hands may cause death, its 
 use cannot be too often condemned as both inefficient and dangerous. 
 Emerson ( I'.ib. i:!!) reports the fatal case of perforation of the esoph- 
 agus and aorta by a chicken iione after blind bouginage in a general 
 hospital. 'I'he author can cite two cases. In one case, seen in con- 
 sultation, a child of two years was dying from acute esophagitis. A 
 penny had lodged in the esophagus five days before. Forceps had been 
 passed blindly, without an esojihagoscope. Two days after this utterly 
 unjustifiable procedure, the temperature was 101°, pulse l-")0. When 
 the author saw the patient, five days after operation, the temperature 
 was subnormal, jjulse fluttering and uncountable, sloughs were being 
 vomited, and the child was sinking away in the profotind shock of a 
 traumatic esoi)hagitis. The author concurred in wording the death cer- 
 tificate: "'Death from acute esophagitis following the swallowing of a 
 ])enny.'' It was really due to the absolute ignorance of the famil\- i)hy- 
 sician who had never iuard of esophagoscopy, and its safety in trained 
 hands. In another case a child of six years was admitted to the Pres- 
 byterian ilos]iil;il with the lii^tory that live days before she had choked 
 and Miniited al dinniT. It was sup]>osetl that a piece of bone had lodged
 
 338 FOREIGN BODIKS IK TUB ESOPHAGUS. 
 
 in her throat. Two physicians liad worked tor two hours with instru- 
 ments on the anesthetized patient, but had failed to remove any foreign 
 body. The child's temperature was 101° F., pulse 128, and respiration 
 28. Appearance septic, breath foul, and swallowing difficult and very 
 painful. Inspection of the pharynx showed a putrid gangrenous mass 
 of mutilated tissues, too severely lacerated to justify examination. Dis- 
 coloration and swelling externally simulated a "Ludwig's angina.'' Sep- 
 tic symptoms steadily increased and the child died five days after ad- 
 mission. Post mortem showed an abscess in left hypopharynx, gan- 
 grenous esophagitis. and bodies of three vertebrae partially denuded, the 
 lowest damaged being the sixth. Macroscopically and microscopically, 
 it was clear that the condition was due to recent trauma, and not to 
 tuberculosis or other disease. No foreign body was found. This case 
 gave a typical example of acute esophagitis from blind etiforts at removal 
 of ?. foreign body. Whether a foreign body had been present or not is 
 not the point. It is one of the sad duties of the esophagoscopist to see 
 little children brought in dying or seriously ill from rough, unjustifiable, 
 brutal attempts to remove a foreign body by such relics of obsolete sur- 
 gery as the Graefe basket, the coin catcher. Bond's forceps, bristle pro- 
 bangs, etc. It may be thought that the bristle probang should not be 
 included here. Possibly its use may not be very dangerous in the 
 adult, but in infants it has been fatal. The author has in his collection 
 of esophagoscopically removed foreign bodies a number of bristles left 
 behind from predecessor's probangs. Sir Felix Semon, with his acute 
 observation and analytical mind, pointed out, years before the develop- 
 ment of esophagoscopy, the danger of attempting to push down a foreign 
 body that was lodged in the esophagus. He reported cases in which the 
 foreign body had escaped such efforts and others in which the foreign 
 body had been forced to perforate. He also pointed out that no foreign 
 body, the presence of which has been actually detected, ought to be 
 allowed to remain impacted, even if at the time it does not produce 
 any serious symptoms. These two principles remain to-day fundamental 
 in dealing with foreign bodies impacted in the air and food passages. 
 Yet it is astonishing how, even to-day, practitioners will tell patients "to 
 go home and forget about it" in some instances, while in others they 
 will produce fatal traumatism by usually unsuccessful blind groping 
 efforts. Emetics are inefficient and dangerous. 
 
 There is but one method of removal worthy of serious consideration 
 and that is by esophagoscopy. It should always be used first. If it fail, 
 which will be very rarely, then external operation is to be considered 
 in cervicallv lodged foreign bodies.
 
 CHAPTER XIX. 
 
 Esophagoscopy for Foreign Bodies. 
 
 Mortality and results of esophagoscopy for foreign bodies* Of 193 
 cases of esophagoscopy for foreign body by various operators, the in- 
 truder was removed in loo. Of the 38 not removed, 26 went down. 
 There were \'i deaths (IM per cent). It is interesting to note that of the 
 twe!\e deaths from esophagoscopy for foreign bodies, eight were for 
 bodies in the upper third, four of the patients dying during operation, and 
 in all four the foreign body was not removed until after death. All had 
 been given chloroform, though this was probably only indirectly the 
 cause of death. In seven of the eight, the eso])hagoscopy was done by 
 operators whose total mimbcr of cases was less than three. In the large 
 clinics (from previously published statistics) out of 210 cases of foreign 
 bodies in this location, all were removed but twelve, and these went down. 
 The mortality in the large clinics was 3 per cent. It is also interesting to 
 note that in the present series of cases there were two deaths from lacer- 
 ation of the esophagus from violent removal of large foreign bodies, an 
 artificial denture in one case, a large and rough bone in the other. In 
 both instances the operators stated, in effect, that they believed they could 
 have succeeded in devising methods of safe removal, had they realized 
 the danger of esophageal trauma. Of the 20(; cases of esojihagoscopy for 
 foreign bodies in the hosj)itals of riltsburgh and in tlie autlim's work in 
 other cities the foreign body was removed in ll'S, and escaped downward 
 in eight. There were four deaths, one in a woman of ."ili with advanced 
 iiei^n-itis; the other llirre deaths were in ]iatients admitted with severe 
 laceration of the esophagus, from i)revious attempts at esophagoscopy. 
 Four other cases seen in extremis are not included because owing to 
 f)roi()und shock no esophagoscopy was doiic. There is not, and there 
 never will lie. an absolutely safe esopliagoscope that can be used other- 
 wise than with care and caution, for even the soft stomach tube has 
 
 •Abstracted, with additions, from tlie autlioi's Uniiport >.u the IiUi'inatiunal 
 Medicat Congre.'^s, T.onflon, IHin.
 
 •340 USOPHAGOSCOPV FOR FOREIGN EODIES. 
 
 caused perforation and death. But all endoscopists are now agreed that 
 skillfully done under the guidance of the eye, esophagoscopy is practically 
 without mortalitv, if considered apart from the trauma incident to foreign 
 bodies and their extraction. 
 
 Indications for esophagoscopy in suspected foreign body cases. 
 Esophagoscopy is indicated in every case in which a foreign body is 
 known to be or suspected of being in the esophagus. 
 
 Contraindications to esophagoscopy in foreign body cases. There is 
 no absolute contraindication to esophagoscopy for the removal of for- 
 eign bodies unless the patient is moribund from esophageal trauma from 
 ill-advised blind efforts at removal ; a state which, while less common 
 than formerly, is still not unknown. If the patient is in bad condition 
 from this cause, it is better to give stimulants, elevate the foot of the 
 bed, keei^i the patient warm with blankets and liot water bottles and use 
 all other means to counteract the shock of acute traumatic esophagitis 
 before removing the foreign body. liismuth taken dry on the tongue is 
 the best local treatment in these cases. If there is a serious state of 
 water hunger from occlusion of the esophagus by a foreign body the 
 esophagoscopy should be postponed until some water can be gotten into 
 the circulation. Water-starved patients make bad subjects for any pro- 
 cedure and as the state is not fully understood the following case may be 
 cited in the words of the pediatrist, H. T. Price, who was associated with 
 the author in the case of cherry stone occluding the previously strictured 
 esopha.gus of a girl of five years. No food or water had been swallowed 
 for five days. 
 
 Report bv Dr. I'rice. "Condition was alarming. Child unable to sit 
 up when placed in a chair, eyes sunken and staring, color very sallow 
 (yellowish ), skin dry and harsh, lips very pale, child spoke with difficulty, 
 seemed bewildered. Pulse almost imperceptible, no further examination 
 made. Ordered normal saline solution by hypodermoclysis and str\ch- 
 nine sulphate hypodermically. Seen about an hour later : condition some- 
 what better, pulse had better volume but was rapid. One pint normal 
 saline given by high enema, all retained and child removed to operating 
 room. During examination child's condition continued to improve and 
 no water expelled in spite of straming. Immediately after removal of 
 cherry stone, while on the table child swallowed water which passed read- 
 ily into stomach and condition steadily impro\ed. Child seemed 'out of 
 danger' from water hunger about eight injurs after admission." 
 
 Aneurysm, serious cardiac and vascular diseases, high blood pres- 
 sure, history of apoi)]exy and tlic like are not contraindications for the 
 cautious esophagoscopic removal of foreign bodies, but thev render 
 esophagoscopy for any other jturpose inadvisaljle. In a foreign body case
 
 ESOPHAGOSCOPY FOR FORKIGN BODIKS. 341 
 
 if there is surgical emphysema, irritability, increasing fever, increasing 
 rapidity of respiration, severe pain in the chest, aching in character, the 
 foreign body has probably perforated and esophagoscopy is of question- 
 able advisability, though in one such case the foreign body had not yet 
 escaped and was caught and removed by the author. The above men- 
 tioned symptoms may be due to pleural perforation, in which case pneu- 
 mothorax can be diagnosticated by physical signs and by radiography. 
 Endoscopic appearances of forci(jn bodies in the esophagus are the 
 same as those previously mentioned in connection with foreign bodies in 
 the air passages e.xcept that the color and form of esophageally lodged 
 foreign bodies may be modified by accumulation of food debris or by 
 bismuth given for radiographic or therapeutic purjioses. Quite fre- 
 quently the first view of a foreign substance will be a whitish or grayish 
 mass of food debris mixed with secretions. The reader is referred to the 
 comments on the difficulties due to the color of a foreign body in the 
 hrimclius which ajiply with etjual force to intruders in the esophagus. 
 Kahier rejjorts a case in which a nodulation due to the calcification im- 
 pressions of the thyroid gland were mistaken for a foreign body in the 
 eso])hagus. 
 
 ESOPHAGOSCOPIC EXTR.VCTION OF FOKKIGX BODIES. 
 
 Anesthesia, preparation of the patient, position of the patient, tech- 
 nic of introduction of the esophagoscope and of the esopliagcal speculum 
 have all been considered in prior chapters. The "Rules" mentioned under 
 bronchoscoi)y for foreign bodies are applicable to esophagoscopy for the 
 same class of cases. As there mentioned it is unwise to go into any for- 
 eign body case insufficiently equipped with the idea of taking a prelim- 
 inary look. Everything likely to be needed for the extraction of the in- 
 truder in question should be sterile and ready for immediate use. A 
 second trial may find the problem incomparably more difficult. There 
 should also lie ready, in every eso])hageal case, a direct laryngoscojie and 
 a bronchoscope, for adult or child as the case may lie. The foreign body 
 may i)e in the air passages, eitlier ])rimarily or by erosion as in the case 
 [jreviously cited: or, more important still, respiratory arrest may result 
 from overriding or displacement of the intruder liv the esophagoscope or 
 by cfli'orts at disimpaction, faulty position of the patient, etc. In such 
 cases iirompt insertion of a bronchoscope and i)ronchosco])ic oxygen in- 
 sufflation may save life wilhmit a tracheotomy. Tracheotomy instruments 
 should always be upon the sterile instrument table as a matter of routine. 
 'J'hose who are prompt and skillful in bronchoscopy will not need them 
 ruid, indeed, it is exceedingly rarely that resjiiratory arrest occurs in 
 esophagoscopy, especially if no anesthesia is used : yet it is a good general
 
 342 ESOPHAGOSCOPY FOR FOREIGN BODIES. 
 
 rule in all traclieo-esophageal cases to have tracheotomy instruments al- 
 ways prepared as a routine procedure for the rare cases of urgent ne- 
 cessity. 
 
 The author has among his personal armamentarium, two lengths of 
 esophagoscopes, one for children and one for adults. It is impossible, in 
 looking through the tube to tell whether a short or the long tube is being 
 used, and so far as instrumentation is concerned, there is no advantage 
 in short instruments, provided the long ones are properly constructed. 
 The little light is close to the foreign body and perfectly illuminates the 
 field, no matter how many instruments are introduced in the tube. All 
 that is necessary is to look past the instruments. The instrument does 
 not lessen the illumination. In using the long tube, if the foreign body 
 is not found at the level where it shows in the radiograph, the entire 
 esophagus is at once explored clear through to the stomach, and even the 
 cardial end of the stomach can be searched. So far as introduction is 
 concerned, a long tube is easier of manipulation than a short tube. A 
 tube of large diameter is always preferable, because with it one is much 
 less likely to override the foreign body ; but on the other hand, a tube of 
 large diameter is much less easy of introduction. For complicated re- 
 movals, such as the closing of safety pins, the cutting of fishhooks and 
 the like, of course the manipulations are much easier through a tube of 
 large diameter. These considerations, however, must not lead us to en- 
 danger our patient by the use of too large a tube. The author uses a 
 tube of 7 mm. internal diameter in children and 10 mm. diameter in 
 adults. In no case is it wise to use a mandrin in exploring the esophagus 
 for foreign bodies. A mandrin makes introduction somewhat easier for 
 the beginner, but it is very likely to cause the overriding of a foreign body 
 in the cer\-ical esophagus, and there is always risk of a diseased esophageal 
 wall w hether a foreign body be present or not. 
 
 Sponging with the long sponge holder should be done very care- 
 fullv. lest the foreign body be hidden in the secretions and lie dislodged 
 by the sponging. It is usually unnecessary to sponge at this stage be- 
 cause the aspirator in the wall of the esophagoscope is draining away the 
 secretions. If small food masses are seen, it is almost certain that the 
 foreign body lies just below, and these food masses should not be wiped 
 away but should be picked out with the forceps lest the foreign body be 
 disturbed. When the tube mouth reaches the proximity of the foreign 
 body, it will be noticed if the foreign body is of sufficient size to distend 
 the esophagus, that the esophagus seems to roll in over the foreign body 
 which only shows in the center of the rather small lumen of the esoph- 
 agus. As the tube mouth approaches more closely, this folding in of 
 the mucosa will be distended and the foreign body comes more largely
 
 ESOPIIAGOSCOPY FOR FOREIGN BODIES. 343 
 
 into view. If the foreign body is a coin or something of that nature, not 
 involving any special problem on removal, it is best not to approach too 
 closely with the tube month: but to insert the forceps just as soon as the 
 foreign body comes into view. The forceps jaws should always open in 
 the up and down direction, regardless of the plane in which the foreign 
 body is to be seen. With all flat objects, this will bring the forceps in the 
 correct iiosition. In case of foreign bodies situated in other planes, or to 
 be seized in other planes, it is better not to rotate the stilette of the for- 
 ceps to make the jaws open in an\ cither plane; but rather to place the 
 handle in the position required for the jaws to open in the proper direc- 
 tion. The advantage of this is that the jaws always open in the same 
 way, making it very much easier to follow their movements by sight. 
 Special problems of removal will be considered later. 
 
 Difficulties. The difficulties of introduction of the esophagoscope 
 have been previously considered. The difficulties of removal will be 
 considered as mechanical problems. But a few words must be said of 
 ditficulties in finding a foreign body known to be present. 
 
 "Overriding," or failure to find a foreign body knoivn to be present. 
 One of the most difficult things for the beginner in esophagoscopy to un- 
 derstand is how a foreign body, especially one not of minute size, can 
 "get lost" in the esophagus. The author is often asked how it is possible 
 for an esophagoscope to be passed many times into the esophagus, and 
 not reveal a penny, for instance, which a radiograph shows to be present. 
 The explanation is found in the anatomy of the eso])hagus. If the 
 esophagus were a tube of equal size throughout with rigid walls standing 
 patulous without folds, or if an esoph;igoscope large enough entirely 
 to fill the lumen were passed, the foreign body would promptly present 
 itself at the lube mouth. But, as shown in Fig. 145, the esophagus is 
 constricteil at certain points which prevents the passage of an esoph- 
 agoscope large enough to lill out its collapsed walls at the larger portions 
 in which small foreign bodies such as needles, pins, and fish ribs may 
 be hidden. P-ut this is not often the explanation of failure to find 
 coins. More often coins and similar (jbjecls are just below the plica 
 cricopharyngeus which latter makes a veritable chute in throwing the 
 end of the esophagoscope forward to override the foreign body and 
 to interpose a layer of tissue between the tube and the coin so that con- 
 tact at the side of the tube after the tube mouth is passed is not felt. 
 Another hiding place for foreign bodies, esi)ecially those of small size, is 
 tlie pyriform sinuses. Food naturally passes through both pyriform 
 sinuses and there is so little room directly back of the cricoid that the 
 esophagoscojie is usually passed through one of the two sinuses, general- 
 ly the right. Therefore if a foreign bodv is not found on the passage
 
 344 ESOPHAGOSCOPY FOR FOREIGN BODIES. 
 
 downward, the distal end of the tube should be kept pressing to the left 
 on withdrawal so as to explore the left sinus on the wav out. Of course 
 if the radiograph should show the intruder to be in the left pyriform sinus 
 the esophagoscope may be passed that way though the retrograde search 
 has the advantage of not risking the pushing of the intruder downward. 
 A better method, however, in all cases of high foreign bodies is to use 
 the esophageal speculum, Fig. 21. This instrument has enabled the 
 author to remove, in three instances, the particularly elusive rib bones of 
 fish after skilful esophagoscopists had failed. In one instance two good 
 tube workers had each tried for two hours under general anesthesia to 
 remove a tish rib which was promptly revealed, not by superior skill on 
 the author's part, but by the advantage yielded by the use of the eso- 
 phageal speculum. The bone was sticking deeply in the esophageal wall 
 just below the plica cricopharyngeus. Coins that have been in the esoph- 
 agus a few weeks show a polished streak up and down the middle third 
 of their anterior (rarely posterior) surface evidently corresponding to 
 the usual course of food in swallowing, the esophagus not being fully 
 dilated, and the lateral edges of the coin being clamped in the lateral folds 
 of the esophageal wall. In some instances the esophagoscope overridmg 
 the tube, probably follows the same route (anterior to the coin intruder). 
 When a silver coin has been in the hypopharynx the central third is 
 darkened by sulphides, while the lateral thirds, corresponding to the 
 pyriform sinuses are bright from passage of the food at the sides of 
 the upper part of the hypopharynx. The intruder may be overridden be- 
 cause it is hidden by secretions, or by being buried under the mucosa or 
 under inflammatory tissue. These are unusual and in most instances the 
 trouble will be found to be the chute-like eiifect of the cricopharyngeus 
 or the lurking of the foreign body in the other pyriform sinus or in the 
 undilated folds of the esophagus, to all of which the use of an esophagos- 
 cope of relatively small diameter contributes. Summarizing, the chief 
 factors in overriding of an esophageally lodged foreign body are: 
 J. The chute-like effect of the plica cricopharyngeus. 
 
 2. The lurking of the foreign body in the unexplored pyriform 
 sinus. 
 
 3. The use of an esophagoscope of small diameter. 
 
 4. The obscuration of the intruder by secretion or food debris. 
 
 ■>. The obscuration of the intruder by its penetration of the eso- 
 phageal wall. 
 
 6. The obscuration of the intruder by inflammatory sequelae. 
 
 Extraction of foreign bodies icith the esophageal speculum. Almost 
 all of the esophageally lodged foreign bodies are to be found at or above 
 the sternal notch. Of these, fully one-half can be removed with the eso-
 
 ESOPIIAGOSCOPV FOR FORKIGN BODIES. 345 
 
 pliageal speculum. It nuust be remembered, however, that, in a radio- 
 graph, a foreign body may look much higher than it really is. Doubt- 
 less this is the reason why so many deplorable, even fatal, attempts at 
 blind removal with forceps are made. It seems an easy task to reach it 
 with almost any kind of forceps — even a hemostat. When an esophago- 
 scope is passed, the reverse mistake is usually made. The foreign body 
 is reached, possibly overridden without being seen, before the operator 
 realizes that he is down to the level indicated in the radiograph. A cor- 
 rect estimate is made more dii'licult by the distortion dependent upon the 
 position of the radiographic tul)e. If the tube be placed exactly over 
 the foreign body, that is, if the intruder and the center of the radio- 
 graphic tube are on the same vertical line, there will be no distortion. 
 But as this cannot be done without knowing beforehand the location of 
 the intruder it would require a repetition of the radiography. For prac- 
 tical purposes it may be said that any foreign body that is not more than 
 one centimeter below the lower border of the cricoid cartilage in a child, 
 or more than two in an adult, is more easily dealt with by the esophageal 
 speculum than by the esophagoscope provided the esophagoscopist has 
 mastered the use of the speculum. lUit all cases can be dealt with by 
 the long esophagoscopic tube, and thorough mastery of it will be more 
 successful than partial mastery of each. In infants the child's size laryn- 
 goscope may be used as an esophageal speculum. 
 
 The introduction of the esophageal speculum is described in a pre- 
 vious chapter. Certain points should, however, be emphasized. The au- 
 thor prefers recumbency of the patient. The head of the patient must be 
 elevated above the level of the table and should be extended fully but not 
 violently. The speculum is held in the operator's left hand as shown for 
 the laryngeal s])eculum in Figs. H!i and IMi. The tip of the instrument. 
 which should be very smooth, is slid intfi the right [>yriform siiuis along 
 the posterior hy[)opliar\-ngeal wall with only enough anterior lifting with 
 the tip to o])en up llu- lunien ahead. No amount of lifting can pull the 
 cricoid cartilage away from the spine, and all the displacement required 
 is to lift the walls of the right pyriform sinus. This at times requires 
 what to some may seem a considerable degree of power, but it is in no 
 case as nnich as reiiuired for a goofl ex]iosure of the larynx by direct 
 laryngoscopy by the dorsolingual route. When the bottom of the pyri- 
 form sinus is reached, it will be known by the obstruction due to the 
 cricoiiharyngeal fold coming forward from the posterior (lower in the 
 recumbent patient ) wall and seeming to cause the lumen entirely to dis- 
 appear. .\t this stage tlu' lip of the speculum should be guided slight- 
 ly tow.ird the median line and lifted. Too powerful lifting here again 
 is to lie ;i\oided because the cricophan,'ngeal fold will follow all the 
 more. It is better to jiusli the speculum, not too forcibly, with the
 
 346 ESOPHAGOSCOPY FOR FOREIGN BODIES. 
 
 thumb and finger of the right hand while the left hand exerts sufficient 
 lifting motion to find the lumen. Just at this point, it is especially ne- 
 cessary to proceed cautiously as the foreign body very often lies im- 
 mediately- below the spasmodically contracted plica cricopharyngeus. 
 If this spasm suddenly relaxes, the foreign body may be pushed down- 
 ward by a sudden advance of the speculum. The head of the patient 
 at this stage must be noted to see that it is high. If not, it must be 
 raised for the reasons explained in the schema. Fig. 149. As soon as 
 the tip of the speculum passes the plica cricopharj-ngeus this fold will 
 obscure the view of half the lumen. The plica should be pushed pos- 
 teriorly with the closed alligator forceps (of Mosher or Paterson) 
 used simply as a repressor, as the tube advances (Plate III, Fig. 3). 
 As soon as the foreign body is seen, if it be a coin, smooth button, or the 
 like, it may be at once seized with the alligator forceps. If it be a 
 sharp, rough, irregular or transfixed body it must be seized according 
 to the mechanical problem presented. In case of such bodies, instead 
 of the plain alligator forceps the author's alligator rotation forceps 
 (Fig. 210) should be used (closed) for the retraction of the plica crico- 
 pharyngeus so as to be ready to seize the foreign body in such a way as 
 to permit of the rotation of the intruder as explained under "Mechanical 
 Problems." 
 
 .Mechanical problems of esopliagoscopic removal of foreign bodies. 
 If an}- argument were needed against the blind attempts at removal, it 
 is the consideration of the various admirable solutions of mechanical 
 problems that have been devised for endoscopic use. To any one who 
 will review this subject, the use of blind methods is preposterous, almost 
 criminal. The esophagus is, surgically, the most intolerant organ in 
 the body. It must be dealt with in the most careful, gentle w-ay, always 
 under the guidance of the eye. The greatest triumph of esophagoscopy 
 over every other method of dealing with foreign bodies in the esoph- 
 agus is in the low mortality of esopliagoscopic methods. The thought 
 that if left, the body jirobably will be fatal anyway, does not justify vio- 
 lence. A careful study of the mechanical problems presented will al- 
 ways discover a safe method of removal. In view of this, the great 
 temptation to remove the body at all hazards once it is grasped, must 
 be resisted. Most of the mechanical problems and their solution as 
 considered in connection with bronchoscopy for foreign bodies, are 
 equally ajiplicable to esophagoscopy. 
 
 As in bronchoscopy side movements of the forceps are accomplished 
 by the leverage of the endoscopic tube, the mouth of which can be used 
 to force the distal end of the forceps in any direction angular to the 
 long axis of the esophagus. 
 
 I
 
 ESOPHAGOSCOPY FOR FOREIGN BODIES. 
 
 347 
 
 Extraction of foreign bodies fixed crosswise in the esophagus. 
 Bodies fixed crosswise in the esophagus present much the same problem 
 and are removable upon the same principle as those fixed crosswise in 
 the bronchi, to which section the reader is referred. There are, how- 
 ever, some problems of crosswise fixation that are peculiar to esophagos- 
 copy. For instance, in the esophagus there is no limit to distance to 
 which a long foreign body may be pushed downward to disengage the 
 point. In the bronchi, however, a long foreign body may already 
 have one end down as far as it can go, so that disengaging the 
 buried upward-projecting point by pushing the foreign body downward 
 becomes a difficult matter. One of the most important things in the 
 
 Fig. 208.— The problem of the horizontally transfixed foreign body in the 
 esopha.i.'US. The point, D, had causlU as the bone, A, was being swallowed. The 
 end, E, was forced down to C, by food or by blind attempts at pushing the bone 
 downward. The wall, F, should be pushed laterally out to J, permitting the forceps 
 to grasp the end, M, of the bone. Traction in the direction of the dart will dis- 
 impact the bone and permit it to rotate. The author's rotation forceps are used 
 as at K. 
 
 removal of a foreign liody from either the esophagus or the tracheo- 
 bronchial tree is to determine at what point the foreign body should be 
 seized in order that it shall come out without injury to the tissues. 
 Therefore, in all cases except those of smooth disk-like bodies, it wcnild 
 be a serious error not to get a good view of the foreign body before at- 
 tempting to seize it with the forceps. In case of thin, sharp foreign 
 bodies, such as bones, needles, double pointed tacks, pins, dentures, 
 safety pins, an<l the like, found, as they often are, crosswise in the esoph- 
 agus, very careful work is necessary (Fig. 208). Foreign bodies reach 
 this ])osition i)n)bably by one point, for instance, D, sticking in the 
 esophageal wall. The foreign bmly is then in the jiosition shown at
 
 348 
 
 ESOPIIAGOSCOPY FOR FOREIGN BODIES. 
 
 A, by the dotted line. The force of the subsequently swallowed food 
 continually pushes the upper point, E, downward until it reaches the 
 maximum stretch of the esophagus, as shown at B. To remove such 
 a body, it is necessary to catch one of the ends, either D or C, never 
 by the middle, B, as traumatism would be almost certain to follow the 
 latter procedure. If either end of the intruder is higher, this is the 
 end to seize. When the intruder is first seen it is usually the central 
 part, B, that is in front of the tube mouth. In order to apply the for- 
 ceps at the end, M, it is necessary to move the esophageal wall, F, out 
 to the position shown by the dotted line, J, by swinging the esophago- 
 scope as a lever, the proximal end of which moves in a direction oppo- 
 
 FiG. 2og. — Solution of the mechanical prolilem of the button or other disk- 
 like object with a sharp point. If withdrawn with a plain forceps applied as at 
 A, the point, B, will rip open the esophageal wall. If grasped at C, the point, D, 
 will rotate in the direction of F and will trail harmlessly behind. To permit 
 rotation, the author's rotation forceps are used as at H. 
 
 site to that desired for the lower end. Pins lodged in the esophagus, 
 are, in the author's experience, almost invariably found point down- 
 ward, exactly opposite to their position in the trachea and bronchi. The 
 probable reason for this is that in the air passages gravity acting strong- 
 est in the head of the pin causes it to fall head lowermost. In the 
 esophagus, which is a collapsed canal, there is less chance for gravity to 
 act effectively, and, more important, pins going head first probably do 
 not lodge, hence, pass on through; whereas, if they start point first, the 
 point will stick into the lateral wall. It is the lodged cases that come 
 to the esophagoscopist. The importance of this as a mechanical prob- 
 lem lies in the necessity for caution in the esophagoscopy lest the head
 
 ESOPIIAGOSCOPY FOK FOREIGN BODIES. 349 
 
 of the pin. impinging on the esophagoscope, may cause the point to per- 
 forate, either by the direct push of the esophagoscope against the pin 
 or the counterpush of the heaving uijward of the esophagus in reflex 
 mo\ements of vomiturition or vomiting. 
 
 Extraction of broad foreign bodies Inning a sharp point. As illus- 
 trateti in Fig. 2o!». if the forceps were used to grasp the foreign body 
 flatly by tlie portion which preseiUed, as shown schematically at A, Fig. 
 2(i'.i, the point, B, would ri]) tlie esophagus open. If, on the other hand, 
 tlie button were caught with forceps which touched onlv at the points 
 and these jminis were applied to one side, as shown at C, as soon as the 
 traction was made, the point. D, would rotate to the position shown by 
 the dotted line. F G, and would lie withdrawn harmlessly. Free rota- 
 tion is permitted by the forceps which touch the foreign body only at 
 the point, as shown at H. The forceps used for this purpose are the au- 
 
 ■30 cm 
 
 Fig. 210. — Author's rotation forceps (short form) for permitting foreign 
 bodies to rotate to the jiosition of least harm and least resistance. For use 
 through the esophageal speculum. 
 
 thor's rotation force])s shown in Fig. 33. For use with the esophageal 
 speculum, the author's alligator form of rotation forceps, Fig. 210, are 
 more convenient. These forceps are dangerous to use otherwise than 
 by sight, because of the possibility of trauma. 
 
 Extraction of open safety pins from the esophagus. II lodged point 
 downward it is necessary only to pwW the pin into the esophagoscope to 
 close it, but in so doing the hook-like protector end of the i)in may cause 
 trauma. It is better to hold the near end of the pin with the forceps 
 while the esophagoscope is pu.shed down over the pin. .\n open safety 
 pin lodged point upward in the esophagus presents certain peculiar ele- 
 ments of danger, and peculiar difficulties of removal. When the esoph- 
 agoscopist sees the [lin in the esophagoscope, the temjitation to seize 
 it and remove it is great. To do so is almost certain death. Besides the 
 risk of septic mediastinitis and iileiiritis. there is the immediate surgical
 
 3.50 
 
 ESOPHAGOSCOPY FOR FOREIGN BODIES. 
 
 risk. Two such cases have come to the writer's knowledge by com- 
 munications. In one instance, death was from hemorrhage into the 
 mediastinum. What vessel was perforated was not known. From the 
 location of the pin, it was probably the aorta. In the other instance, 
 shock from esophageal trauma was the cause. In adults or older chil- 
 dren, the pin can be closed before removal as described in connection 
 
 Fig. 211. — Radiograph by Dr. George C. Johnston, showing open safety pin, 
 point up, in the esophagus of an infant, aged eleven months. Pin was passed into 
 stomach, turned and removed esophagoscopically. Pin retouched for clearness. 
 (Author's case). 
 
 with safety pins in the bronchi. The author has had a number of such 
 cases. In infants, the esophagus is already in such a state of tension by 
 the stretching spread of the spring (E, Fig. 212), that perforation is cer- 
 tain if the dilatation of the insertion of an instrument be added. The 
 solution of the mechanical problem of safe removal when the first under- 
 noted case presented itself, led the author to devise a new method which
 
 ESOPHAGOSCOPV FOR FOREIGN BODIES. 
 
 351 
 
 is practicable for anyone who has practiced gastroscopy. Republication 
 here of a report (Bib. 25(i) of the first two cases will suffice to illustrate 
 the method. 
 
 Elizabeth G., aged eleven months, referred by Dr. August Soffel 
 and Dr. C. C. Sandels. .Admitted to the Eye and Ear Hospital August 
 13, 1909, with a history of having swallowed a safety pin. .\ radio- 
 graph (Fig. 211), by Dr. Oeorge C. Johnston, showed the pin to be of 
 large size and spread so widely open that it seemed certain, considering 
 
 Fin. 212. — Schema showing the author's method of removal of upward pointed 
 esophageally lodged open safety pins by passing them into stomach, where 
 they are turned and removed. The first illustration (A) shows the rotation for- 
 ceps before seizing pin by tlie ring of the spring end. (Forceps jaws are shown 
 opening in the wrong diameter). At B is shown the pin seized in the ring by the 
 points of the forceps. At C is shown the pin carried into the stomach and about 
 to be rotated by withdrawal. D, the withdrawal of the pin into the esophagoscope 
 which will thereby close it. If withdrawn by flat-jawed forceps as at F, the eso- 
 ph:igc;d wall would be fatally lacerated. 
 
 the age of the patient, that the esophagus was perforated. The tem- 
 perature lli'i.l, the res])iration 10, the jmlsc 1 10, weak and irritable, all 
 plainly indicated aiute esophagitis. To use the safety pin closer, which, 
 because of the small esojihagus, would have to be passed external to the 
 tube, before the insertion of the tube, was not to be thought of for the 
 reason previously given. The aiUhor had made the forceps shown in 
 Fig. 33. Passing the esophagoscope under ether anesthesia, the pin 
 was quickly located, surrounded by an area of acute esophagitis. The
 
 352 ICSOPHAGOSCOPY FOR FOREIGN BODIES. 
 
 point was buried the full extent of the taper. Under ocular guidance, 
 the author seized the pin by the ring, as shown at B in Fig. 213. Fol- 
 lowing with the esophagoscope, the pin was pushed downward, thus 
 withdrawing the jioint of the pin from its bed in the esophageal wall 
 and gently carrying the pin, secure;ly held, but free to move, down into 
 the stomach as shown at C, Fig. 213. Withdrawal of the forceps turned 
 the pin by the keeper and the point striking the wall of the stomach ; 
 and the pin was pulled into the esophagoscope sufficiently far to close it, 
 though it was too large to be removed through the tube. The esoph- 
 agoscope, forceps and pin were all withdrawn together. Dr. Homer 
 McCready, who manipulated the aspirator, reported no stain of blood in 
 the secretions. The entire procedure required but se\en minutes. The 
 fever subsided in a few days and the child went home well. 
 
 Remarks. The action of the forceps will be understood from Fig. 
 312. If the ring were seized with the ordinary flat-jawed forceps (as at 
 F). the pin could not be turned without risk of losing it and causing 
 delay. The special rotation forceps hold the pin securely at the ring 
 but allow it to turn freely without letting go. The pin cannot turn the 
 full ISO degrees, but it can turn far enough to allow it to be drawn into 
 the tube where it is safely housed for removal. If a small pin, it can be 
 withdrawn through the tube as in the second case. The question may 
 be asked. Why is it safer to turn the pin in the stomach than in the esoph- 
 agus? There is more room, so that there is no pressure on the point of 
 the pin, the pin being free to turn ; and, most important, the stomach wall 
 is thick and strong as compared to that of the esophagus, though we must 
 not be tempted into roughness by this. Gastroscopic manipulations must 
 be gentle. 
 
 Margaret K., aged fourteen months, referred by Dr. F. L. Ives. 
 A radiograph (Fig. 214) by Dr. L. Gregory Cole, of New York City, 
 showed the ])in to be lodged point upward in the esophagus. At the 
 Eye and Ear Hospital, two days after the swallowing of the pin the 
 author removed it by the same method as in the ]>revious case, but, being 
 smaller in size, the pin could be withdrawn through the tube. The child 
 returned home well on the second day. Illustrations of the pins are 
 shown in Chapter XXI. 
 
 So far the author has not lost the pin from the grip of the forceps 
 while at work on a case. Twice, however, in demonstration work de- 
 fective forceps allowed the pin to escape. It was thus discovered that 
 the forceps must be made exactly as shown in Fig. 33. 
 
 D. R. Paterson has devised a very ingenious method of passing a 
 small tube over the point of the safety pin and then catching the safety 
 pin by the other limb and thus removing it safely, the little tube, forceps.
 
 KSOPHAGOSCOPY FOR FOREIGN BODIES. 
 
 353 
 
 pin and esophagoscope all bciug- brought out together. Alosher, Hub- 
 bard and others have devised very ingenious pin closers. 
 
 Extraction of double pointed tacks and staples lodged point upward 
 in the esophagus. If very .short these objects could be turned by grasp- 
 ing them by the lower or curved end. A safer method and one that 
 must be adojHcd in case of longer tacks or staples is to carry the in- 
 
 Fic;. 21.^. — l.aKr.il railiMiiiaiih U'> I'l- tlcuiyc C. Juliii,-.l(jn ) i.i a satcly pin in 
 a cliild of II months, demonstrating the esophageal location of the pin in this 
 ciise and the great vaUie of the lateral radiograph of foreign body cases. (.\uthor's 
 case. See Fisrs. 272 and 212.) 
 
 truder down into the stomach there to l)e turned as described for safety 
 [lins. The safety pin or rotation forccjjs ( b'ig. :'>:>') must be used. L'nder 
 no circumstances should sucii an intruder be pulled upon with the ordi- 
 nary forceps. 
 
 Extraction of fish hooks from the esophagus. The author has never 
 yet had to dcrd endoscopically with a fish hook, but there are four nielli-
 
 354 
 
 KSOPHACoSCorV l-'OR F(1Ki:ir..\ BODll-lS. 
 
 ods by which the mechanical ijroblem can probably be solved. The first 
 of these is that bv which 1). R. I'aterson removed a fish hook from the 
 le\el of the boily of the fifth dorsal vertebra of a boy aged thirteen 
 years. The hook had the usual gut leader aljout nine inches in length 
 projecting from the patient's mouth. Dr. Paterson passed the esophago- 
 scope over the gut leader and then threaded a bronchoscopic aspirating 
 tube over the leader so that when passeil down to the level of the hook 
 the bulhovis extremity of the aspirating tube fitted into the curve of th-^ 
 
 Fin. 214. — Radiograph by Dr. L. Gregory Cole, (New York), showing safety 
 pin in the esophagus of an infant ageil fourteen months. Passed into the stomach, 
 turned and removed under esophagoscopic guidance. (Author's case). 
 
 hook which was thus safeguarded and withdrawn. In the event of en- 
 countering a hook that has an eye instead of the gut leader, forceps 
 could be used to thread a braided silk through the eye and then the 
 distal end being brought up we would have a double thread coming oiTt 
 the mouth. Over this double thread the aspirating tube could be passed 
 as was done by Dr. Paterson in his case. In the event of the eye being 
 too large to pass through the as|iirating tube, a similar tube could be 
 readily constructed for the ptu-posc with a larger lumen, or a flattened 
 lumen, if necessary. A second method would be to use the pin cutting 
 forceps. Fig. o-i. These, however, would ;iroIial)l\- not extract the frag- 
 ment, if the barb was buried in the esophageal wall, though if properly
 
 KsopiiAc.osCDPV KiiK i'oRi;ir..\ r.oniKS. 355 
 
 coiislriicK-(l tlic\- sliiiiilil hold the iragnicm if the barh was nut hurieil. 
 The loss of ihi- jioinl wiili the harlj would ccrtainl\- be a ri>ky iinn'cdun.- 
 because of the certainty of the barb working its way through distant 
 tissues. While the patient might possibly escape serious injury from 
 this cause, the author believes that the third method will be found the 
 easiest and the most practical as well as the most certain. 'I'his co.i- 
 sists in i)assing the tish hook down into the stomach, turning U anil 
 bringing it out with the curve end first, the point trailing behind, if too 
 large to pull the entire curved jiart of the fish hook into the distal end of 
 the esophagoscope. This procedure would be precisely the same as 
 mentioned in regard to safety pins and fence staples. This has been so 
 re;idilv accomplished b\- the author in dealing with safety ])ins and staples 
 that he feels (|nile certain that it could be even more readily done in the 
 case of the fish hook. Pressure downward with the forcejis after grasp- 
 ing would certainly extract the barb. A fourth metluul wuuld be by 
 catching the point and barb in the tissue forcei)S, Fig. :i-"i, after pushing 
 the hook (hnvnward sul'ficiently to disembetl the barbed end. Thus pro- 
 tected with the box-like covering of the tissue forcejis the intruder could 
 l)robably be withdrawn harmlessly. As before stated the author has had 
 no opporlimity to deal with the fish hook [)roblem in the human being 
 but he has practiced these jirocedures until he believes that each of then' 
 can be done upon the luunan lieing b\- very careful work. l'"or such 
 manipulations he would deem a general anesthetic advisable unless abso- 
 lutely contraindicated. 
 
 Ilxtraction of foreign bodies cj large sirjc from the esophagus. The 
 removal of very large, rough and sharj) bodies, such as bones and arti- 
 ficial dentures, from the esophagus cleserves special consideration. .Many 
 cases have been needlessly (and occasionally unsuccessfully) ojierated 
 externally, 'i'he esophagus is a highly sjiasmodic tube. One of the 
 functions of nausea is to relax the esojihagus and prevent spasm in order 
 to t;u'ilitate \omiting though, of coin-se, \omiting can occur without 
 nausea. \\ hen the attem[)t is made to withdraw a foreign body spasm 
 is excited and constriction occurs. This h;is been fre<|uentl\- demon- 
 slnited to others by the anilior. W In n a bodv is large, sharp and rough 
 the spasm excited is much greater .ind even if it were not, constriction 
 means more with such a body th.an with a small, smooth. riJinid otie. It 
 ought n(]t to re(|uire nnich argument to convince an\-one of the neces- 
 sity of the relaxation of deep general anesthesia for all cases of esoph- 
 agoscopic removal of large, sharp or rough foreign bodies. With 
 such relaxation ;niy intruder, no matt<-r how l.irge or sh;n-[). lh;it has 
 .gone down through natural ])assages can come up the s.ime wav : pro- 
 vided thai, in the withdrawal, as occurred naturalh- in the intrusion tlie
 
 356 ESOPHAGOSCOPY FOR FORICIGX BODIKS. 
 
 intruder is turned to the most favorable position. It is necessary to re- 
 lax not only tlie esophageal musculature itself but also the musculature 
 which acts upon the surrounding hard and soft anatomic structures, such 
 as the action of the constrictors on the cricoid cartilage and even the 
 diaphragmatic musculature in the rare cases of withdrawal of a foreign 
 body from below the hiatal level. In case of small foreign bodies, the 
 relaxation of deep anesthesia may lose the intruder downward. In large 
 impacted bodies there is no likelihood of this, but procedure must be 
 careful to avoid respiratory arrest as before mentioned. 
 
 IMillspaugh (Bib. 383) in a very interesting paper, reports the re- 
 moval of a large vulcanite plate on which were two teeth, demonstrating 
 clearly what careful manipulations can do in the removal endoscopically 
 of these large foreign bodies which heretofore have been considered as 
 demanding external operation. The interesting case of esophagoscopic 
 removal, by Dr. D. Braden Kyle, of a vulcanite tooth plate is reported 
 in a subsequent paragraph. 
 
 In exceptional cases it may be necessarv to comminute a large for- 
 eign body, as was done by Killian with rare skill in case of a vulcanite 
 tooth plate. 
 
 Extraction of nwat and other foods from the esophagus. Meat in 
 the esophagus, after it has become macerated, can sometimes be re- 
 moved very readily with forceps. In many cases, hovv^ever, the mechan- 
 ical spoon. Fig. 40, will be found verv much better, inasmuch as it can be 
 placed belovi' the meat, the spoon turned up and the meat pulled en masse 
 into the mouth of the esophagoscope. 
 
 Extraction of foreign bodies from the strictiired esophacjns. At 
 first thought, it might seem unusual to have the combination in the same 
 case of a stricture of the esophagus and a foreign body. Yet such a com- 
 bination is by no means infrequent. Foreign bodies of relativelv small 
 size will lodge in a strictured esophagus, but would pass through a 
 norma! gullet. Children, especially, will fail to masticate food thorough- 
 ly, or will allow the foreign body, such as chewing gum, grape pulp, in- 
 cluding the seeds, orange seeds, watermelon seeds, and the like, to slip 
 down. The author had one case where he removed, at diiTerent times, 
 four different foreign bodies from the esophagus of one child under- 
 going treatment for stricture. The situation becomes still more com- 
 plicated when the patient has an upper stricture relativelv larger than 
 the lower one, and the foreign body passing the first one lodges at the 
 second, and still more difficult is the case if the second stricture is con- 
 siderably below the first and not concentric. Under these circumstances, 
 it is best to divulse the upper stricture mechanically with the divulsor 
 shown in Fig. 'i2, when a small tube can be inserted past the first stric-
 
 ESOPHACOSCOl'Y I'OR I'OKKIf.N BODIKS. 357 
 
 lure, thus at tlic same lime simplifying tlie removal and accomplishing 
 one stage of the treatment for the stenosis. In some of these stricture 
 cases bismuth may completely occlude the lumen of the stricture when 
 given in the large quantities sometimes required for a radiograph. This 
 is much less apt to follow a mixture of bismuth with milk than with 
 bread or porridge. In either case it is not difficult to remove the bismuth 
 esophagoscopically, using the sponges in the sponge holder, and, if neces- 
 sary, the mechanical spoon until the lumen of the stricture is reached, 
 when the opening may be found 'vith a small jirobe, and afterwards small 
 olives can be passed. The surplus bismuth should be removed upward 
 so as not to occlude the canal again. Usually such patients can regurgi- 
 tate a large jiart of the contents of the esojihagus, and it remains only 
 for the esophagoscopist to clean out the remainder by the means men- 
 tioned. 
 
 Extracluni of fovc'uin bodies after prolonged sojourn hi the esoph- 
 agus. The leading case is that of D. IJraden Kyle (Bib. 3V.>). A 
 tooth plate had remained in the esophagus for eighteen years. A phy- 
 sician called shortly after the accident assured the patient that the teeth 
 were not in the esophagus on the strength of a negative result with 
 bougies and jjrobangs. The tooth plate was located radiographicall)' 
 'Fig. S]-")). With the esophagoscope, Dr. Kyle found the foreign body 
 eighteen centimeters from the upper teeth. The upper edge was cov- 
 ered with fibrous tissue. At four sittings. Dr. Kyle in his careful, skill- 
 ful way disimpacted and removed the tooth plate from its bed. The 
 patient had slight difficulty in swallowing for a time, but in three months 
 could readily swallow semisolid food. 
 
 In these cases of prolonged sojourn ui the foreign body in the esoph- 
 agus, the inflammatory exudate will contract after the foreign body 
 is removed and stricture of greater or less extent is almost certain to 
 follow, so that in all such cases, it is wise to keep a close watch on the 
 patient, and if stricture follow, it should be treated bv the same methods 
 as other cicatricial stenoses, to be considered later. 
 
 Foreign bodies buried in Pha>-yn(/eal and esopha(/eal tissues. In 
 cases of needles, headless pins an<l tin- like haxing entered and disap- 
 peared in the tissues of the pharynx, they should be followed through 
 the wound of entrance if this can be found. Otherwise, the\- should be 
 searched for l.y finger palpation aided by accurate localization witli both 
 an anteroposterior and a lateral radiograjih. When tints located an in- 
 cision should be made crosswise to the long axis of the pin. This is im- 
 lierali\e, because if the incision is parallel the ch.uiccs of striking the pin 
 are remote. Two cases of this kind were seen in the autiior's service 
 at the Eye and Ear Hospital. In one of these, previously reported (Bib.
 
 358 
 
 F.POPHAC.OSCni'Y KOR FORlvIGN BODIKS. 
 
 2(!St, page ]'27), a doulik- i>()inti.-il pin had wandered from the wound of 
 entrance and was removed from the posterior wall of the laryngopharynx. 
 In the second case, that of a needle in the tissues back of the hypo- 
 pharvnx of a woman of fnrtv years, the needle was accurately located Ijy 
 anteroposterior and lateral radiographs by Dr. Russell H. Boggs. It 
 could not he palpated because of its depth; but by an endoscopic estimate 
 of the radiographically determined distance of the center of the long 
 axis of the needle upward from the cricoid cartilage, a crosswise in- 
 cision with the long laryngeal knife (Fig. 85) passed through the eso- 
 phageal speculum (Fig. "M ), the author w'as so fortunate as to strike the 
 
 Fig. 215. — Radiograph showing tcoth plait in ihc csophagns where it had been 
 for 18 years. (Removed by Dr. D. Braden Kyle). 
 
 needle at the first incision. The wound was covered with bismuth sub- 
 nitrate by insufflation. Dismuth was ordered in five grain doses dry on 
 the tongue every hour. Healing was complete in about a week, without 
 any rise of temperature or complication except slight subcutaneous 
 emphysema which subsided in a few days. When foreign bodies have 
 invaded the intrathoracic periesophageal tissues, it is unwise to make 
 an incision to reach them, and even through the wound of entrance it is 
 unwise to pursue them far. It is. howe\er, justifiable in cases in which 
 there is local or radiographic evidence of a buried foreign body, care- 
 fully to explore the wound b\- instrumental palpation. The best explor-
 
 KSOPIIAC.OSCOl'V I'OK l'(IRl-JC,\ i;()DIES. 359 
 
 ing inslrumcnt for this i)urpose is the forceps. Fig. 28, which are inserted 
 closed. Should the exjiloration transmit the sensation of a foreign body 
 the forceps are expanded and the foreign body is seized. This explora- 
 tion refers onlv to recent cases with a \isil)le woimd of entrance or those 
 in which the wound channel is marked by granulation tissue. Where the 
 foreign body has perforated the anterior esophageal wall at any point 
 above the tracheal bifurcation, the foreign body may be found in the 
 trachea of which an instance is elsewhere herein reported. If there is 
 no wound \isible, fluoroscopic aid for localization may be sought as else- 
 where mentioned, but great care must be used. 
 
 As pointed out by Ingals li'.ib. -i-ii)) — "An operator must not too 
 readily conclude that something w iiich to him appears unnatural is the 
 wound through whicii a coin or InUlon that cannot be found has made 
 its way into the esophageal wall, for in the great majority of cases it 
 would be very much more likely that such a foreign body was hidden by a 
 fold of edematous tissues." I'nder no circumstances is it justifiable to 
 explore except in the most gentle way an apparent wound in the eso- 
 phageal wall and even careful exploration should not be atteinpleii until 
 the entire esophagus has been explored for the foreign body and ;i radio- 
 graph has been taken to determine whether or not the foreign body has 
 emerged through the eso])hageal wall. The author has seen five cases 
 of abscess of the esophagus from foreign body traumatism and in two 
 of the cases the foreign body was lodged inside the abscess, in one such 
 case of the autlior, referred by T^r. Clarence M. Harris, the patient was 
 unal)le to swallow. I'lJon i)assage of the esophagoscope the esophagus 
 was found occluded at the level of tlic lower liorder of the cricniil by a 
 smooth rounded swelling on the ajiex of which was a small crater-like 
 opening. The pressure of the tube caused pus to exude and the abscess 
 was thus completely exacuated. The patient b;id no further difliculty in 
 swallowing though there was slight odynphagia for a few da_\s during 
 which bismuth subnitrale and calomel were given. Comjilete recovery 
 res'.dted in one week. .\f) foreign boily was found in the jms .nul it 
 was (|uite clear that the abscess resulted simply from the infectixe intlam- 
 mation of the ])micture of tlie foreign hotly, a bone. 
 
 Flitroscopic csopluifioscopy seems to the .-nUhor an unjustifiable pro- 
 cedure. In case (if foreign bodies tliat have entered bronchi too small 
 for an endosc(jpic lube to enter, the foreign body cannot be found ex- 
 cept by relatively blind endoscopic melbi)ds ami therefore fluoroscoi)ic 
 bronchoscopy may have a legitimate, tiiougb limited, field of usefulness, 
 r.ut in the esophagus where every S(|uare millimeter of surface is explor- 
 able by sight, Huoroscoi)ic esophagoscopy is a step backward that is un- 
 justifiable. .\ jiossible use for the tlunroscoi)e in this comiection would
 
 360 ESOPHAGOSCOPY FOR FOREIGN EDDIES. 
 
 be in a case of a foreign body having wandered out tlirough the esoph- 
 ageal wall. ir. which case it is no longer a foreign body in the esoiihagns. 
 To pursue it under fluoroscopic guidance would be more danger- 
 ous than external operation. If the latter is not advisable at once the 
 wanderings of the invader can be watched radiographically and oper- 
 ation deferred until the foreign body reaches a favorable location. In 
 case a foreign body shows clearly in a radiograph, after the esophago- 
 scopic search has proven negative and no wound of entrance is discov- 
 erable, it is advisable to use the fluoroscope to obtain accurate localiza- 
 tion of the position of the foreign body simply to explore the wound 
 endoscopically under ocular guidance to the limited extent such explora- 
 tion may be deemed advisable. Unfortunately this can be done only in 
 very recent cases and even in these the intruder may have traveled far, 
 so that it may be nowhere near its wound of entrance. It is usually pins, 
 needles and similar slender, sharp pointed bodies that escape through 
 the esophageal wall. The author had one case, that of a common pin 
 that had escaped — all but the head. He was fortunately able in this par- 
 ticular instance to find the head endoscopically and remove the pin ; but 
 he can easily see how information from the fluoroscopist working jointly 
 with the endoscopist could, in such a case, give assistance of the utmost 
 value, especiallv with the <loul)le-pIane fluoroscope dexised for the author 
 by Dr. drier. 
 
 In cases of bodies of irregular shape the fluorescent screen affords 
 no evidence whatever that the foreign body is being so seized that it will 
 not lacerate the esophagus during withdrawal. 
 
 As mentioned by D. R. Paterson injurv has been done by fluoro- 
 scopic esophagoscopy. While successful in some cases with smooth for- 
 eign bodies the fluorescent screen does not enable the operator to make 
 sure that he is not seizing any mucosa along with the foreign body. As 
 stated by D. R. Paterson and concurred in by all other esophagoscopists 
 of experience "It is surely more in accordance with surgical principles to 
 see a foreign body in situ, and so define its relations to the surrounding 
 esophagus." 
 
 Complications and dangers of esophagoscopy for foreign bodies. 
 Asphyxia from pressure of the esophagoscope. plus the bulk of the for- 
 eign body, or, in some instances, by the foreign body alone without any 
 esophagoscopy, is a possibility. The danger of the esophagoscope causing 
 asphyxia is enormously increased by general anesthesia. The author's 
 schematic representation of this (P.ib. 2(!9, p. 14';), has been abundantly 
 born out by frequent reports of deaths on the table during esophagoscopy, 
 and especially esophagoscopy imder general anesthesia. Such a possi- 
 bility is very much greater with chloroform than with ether, because of
 
 ESOPIIACOSCOPY I"OK rOKKlGN nODIKS. 361 
 
 the stimulant effect of ether on the respiratory center, and the paralytic 
 effect of chloroform. Cocaine poisoning, due to the use of an anesthetic 
 solution, or of too strong a solution, has been reported. The viselessness 
 of local anesthesia for esophagoscopy has been elsewhere mentioned. If 
 local anesthesia is ever needed for esophagoscopy, it certainly can be 
 needed only in the one pyriform sinus, through which the esophagoscope 
 is to be passed. In making the application to the pyriform sinus, there 
 will be enough of the solution applied to the pharynx inevitably by the 
 spread of the secretions, so that no special application is needed, except 
 in the [lyriform sinus. Such a limited apjilication can involve no special 
 risk in adults. Children are very susceptible. Septic mediastinitis with 
 cellulitis of the neck has been seen three times in consultation by the 
 atuhor. He advised, in each case, and upon request, performed in one 
 of the cases, a drainage of the region back of the esophagus by a long 
 incision along the sternal mastoid muscle, with dry dissection deep down 
 along the esophagus uiuil the perforation was found. In two of the 
 cases, perforation had been caused by the foreign body ; in one instance 
 spontaneously, and the other in removal. The third case was caused by 
 perforation by the blind passage of a bougie. In both of the cases 
 emphysema, with intense dyspnea, followed immediately after the acci- 
 dent, requiring tracheotomy in two of the cases. The cellulitis developed 
 witlun forty-eight hours. All of the cases recovered after drainage. 
 Perforation of the esophagus by either the foreign bodv or by the esoph- 
 agoscope. may occur. The foreign body, especially sharp pointed pins 
 and bones, may erode its own way through the esophagus either by ulcer- 
 ation or even by direct puncture, but much more frequently, the introduc- 
 tion of instruments blindly, or even occasionally the introduction of the 
 esophagoscope may force the foreign body through the wall. Very 
 careful work will prevent any assistance to perforation during esoph- 
 agoscopy, but the possibility should be borne in mind. In regard to 
 perforation of the wall with the eso])hagoscope, such a thing is exceed- 
 ingly rare in skillful bands and with a sound esophageal wall. It nuist 
 be borne in mind, however, that the esophageal wall may be weakened 
 by ulceration, or by malignant disease, or aneurysm so that the tube will 
 meet with jjractically no resistance in making a false passage. As else- 
 where mentioned, the greatest danger exists in the neighborhood of the 
 cricoid level from the contraction of the annular fibers of the crico- 
 jiharyngeus. The most serious accident that can occur is a gangrenous 
 esophagitis which is almost invariably fatal. Such a complication can 
 occur only from the most gross and brutal attempts by one who is not 
 only totally ignorant of the procedure, but is not ordinarily careful in his 
 manipulations and who is not careful of his ascjitic technic. The worst
 
 362 KSOPHAGOSCOPY FOR FOREIGN BODIF.S. 
 
 case of gangrenous csopliagitis that the author ever saw was due to bHnil 
 attempts to remove a foreign body which probablv was not present. 
 Forceps had been used bhndly on what the surgeon told the relatives 
 was a bone that he could feel. At autopsy, the bone proved to be the 
 cervical vertebrae, the bodies of three of which were denuded. The 
 surgeon, who had never previously bandied an esophagoscope attempted 
 esophagoscopy, and failing in that, resorted to the blind use of powerful 
 forceps. The symptoms are, profound shock, high temperature early in 
 the case and a subnormal temperature later, a weak rapid pulse, great 
 restlessness, low moaning or muttering delirium, and quite characteristic 
 is the putrid odor of the breath. 
 
 Treatment. The treatment of acute esophagitis consists in rest, ster- 
 ile licjuid food, and the administration of small doses of bismuth and 
 calomel frequently repeated. The calomel may be discontinued when it 
 acts too freely on the bowels, and the bismuth continued alone. Local 
 applications of cold, such as with an ice bag, can be used where the 
 trouble is in the cervical esophagus. Rest of the esophagus is best ac- 
 complished b}- gastrostomy for the giving of food and liquid, Imt in the 
 class of case now under consideration, gastrostomy would be rarely ad- 
 visable. The teeth and mouth should be kept in as clean condition as 
 possible, and alcohol, "i.") per cent, should be used to rinse the mouth at 
 least once an hour. This, with sterile food, will limit the activity of the 
 mixed infections, which are the most dangerous complications after eso- 
 phageal trauma. Emphysema does not usuallv re(|uire anv si>ecial treat- 
 ment for the leak soon becomes obliterated and if no infective conditions 
 follow, the emphysema will usually subside itself. An occasional case, 
 however, may be encountered where it is necessary to puncture the skin 
 in many places in order to liberate the air, though the author has never 
 yet seen such a case. In the event of the pleura being perforated, imme- 
 diate signs of shock and pleuritis are apt to develop and pneumothorax 
 will show its characteristic signs within twelve hours. If tapped imme- 
 diately, there may he, in this short time, the characteristic fecal odor from 
 bacterial activity. If the mediastinum has not also been infected, a 
 proni[)t ojicning of the pleura may sa\e the patierit.
 
 CHAPTER XX. 
 
 Pleuroscopy. 
 
 Pleuroscopy for foreiyn bodies. The author has, in one instance, 
 removed a foreign body, a primer from a shotgun cartridge. Figs. 21 ti 
 and 217, from the pleural cavity through a small opening made in the 
 chest by Dr. J. Hartley Anderson. This was done immediately after the 
 accident and there was no odor or pus at anv time. General anesthesia 
 was given, and the child, after the chest opening was made, was placed 
 in the sitting position in order that the foreign body would fall to the 
 diaphragm. Healing was prompt and the air began to enter the lung 
 on the fifth day. The child made a prompt recovery, and now, about 
 three years after ihe uperation. is in iierfect health. In this class of 
 cases, pleuroscopy promises excellent results if done immediately, before 
 infection or inflammation has set in. ( )nly a small opening is necessary, 
 and this does not invoke anything like the shock consequent upnn the 
 large osteo]dastic fia]). The only shock is the pleural shock, which is 
 slight, and which in the author's case was ])resent anyway because there 
 was already ;i I'luiimothorax before the chest was opened. 'IMie instru- 
 ment used by the author was the adult esophageal specidum (Fig. 2\) 
 with liandle detached. This instnunent ga\e a large \iew, and the spat- 
 ular end was \ery con\enient lor moving tlie lung out of the \v;i\\ as the 
 greatest difficulty encountered was in the manipulation of the lung, which 
 was flopping about like a live fish dangling at the end of a fishing line. .\ 
 small drain was put in as a precaution. The absence of pus or an\ cnn- 
 siderable C|uantity of secretion raises the c|uestion as to whether or not it 
 would have been better to have closed the wound tightly and aspirated 
 the pleural air. It would seem that the possibility of a valvedike action 
 of either the parietal or the visceral ])leur;i |)ermitting leakage ;inil com- 
 pression of the mediastiiuim and other lung, seriouslv imjiairing the nega- 
 tive pressure needed to make the other hmg serviceable, wotdd involve 
 grave risk. 
 
 \\'hether done by ])lcuroscoi>y or not. immediate remo\al of a foreign 
 body as soon as it is discovered in the lung is advisable.
 
 364 
 
 PLKUEOSCOPY. 
 
 Fleuroscopy offers no hope of finding foreign bodies still in tlie huig. 
 
 Plcuroscot'V tor disease, rieuroscopy for exploration and treat- 
 ment of pleural diseases is quite feasible through a relatively small open- 
 ing without rib resection. It is, of course, to be thought of only when 
 
 Fig. 2i6. — Radiograpii showing luicigii body (.primer) at the bottom of the 
 pleural cavity of a child of four years. Foreign body (Fig. 217) removed by 
 pleuroscopy. (Author's case.) 
 
 9 
 
 FiG. 217.— Primer removed from the pleura of a boy of four years by pleuros- 
 
 copy. 
 
 for some reason, a large opening is not desired. Most pleural diseases, 
 however, require a large external opening for drainage and these permit 
 inspection without endoscopy, though even in case of large openings the 
 esophageal speculum by its light and its spatular use in the moving aside 
 the lung is a great aid to exploration in the otherwise dark pleural cavity.
 
 
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 CHAPTER XXI. 
 
 Illustrative Cases of Endoscopy for Foreign 
 Bodies in the Air and Food Passages. 
 
 As the factor paramount m peroral endoscopy is the mechanical prob- 
 lem of extraction, and as this problem is dominated by the nature of the 
 foreign body, the following cases are grouped by the character of the in- 
 truder rather than by chronological or anatomic data, so that the endos- 
 copist about to deal with a foreign body case may, without unnecessary 
 delay in page-turning for cross-references, see the problem similar bodies 
 have presented, and how they were dealt with, successfully or unsuc- 
 cessfully. For similar reasons subordinate matters, such as previous 
 bronchoscopies by other operators,''' symptoms, and even entire cases of 
 no particular interest have been omitted. The fundamental importance 
 of the duration of the operation being recognized by all endoscopists, it 
 is given under "Time," if recorded. If this were invariably done by all 
 endoscopists, an approximate estimate of the advisable time limit would 
 soon be obtained. The location at the time of removal and the length 
 of sojourn are given together, though it was not always known how long 
 the intruder had been in the particular location stated. 
 
 It will be noted that chloroform is mentioned in the earlier cases. 
 This is no longer used by the author, except that if ether fails to produce 
 complete relaxation in the cases of very large and very sharp foreign 
 bodies in the esophagus a little chloroform may be added for relaxation 
 after the stimulant effect of ether makes chloroform safe. All the late 
 cases in children were done without anesthesia, general or local. "Point 
 of seizure" refers to the part of the foreign body seized or the manner 
 of seizing it. The rotation forceps come together only at the points thus 
 permitting rotation to the position of least resistance during withdrawal 
 or such rotation as would facilitate the disimpaction of one point of 
 pointed transfixed bodies, as explained in the two sections on "Mechanical 
 Problem.s." "Alligator rotation" forceps (Fig. 210) are used through 
 the laryngoscope and esophageal speculum. Where simply "alligator" 
 is given, it refers to an elongated form of Mosher's alligator forceps. 
 The cases include those done by Dr. Ellen J. Patterson as well as those 
 by the author. 
 
 As illustrations of modern coins is forbidden bv law, special permis- 
 sion was obtained from the United States Government for the making 
 and publishing of the illustrations below. 
 
 •In about 45 per cent of the cases here recorded removal had been previously 
 attempted by others. About 15 per cent arrived in a serious state from trauma of 
 roug:h attempts. In many cases the mechanical problem had been converted from 
 a very simple into a very difficult one. Moribund cases are not included here 
 because no endoscopy was done by the author. All of which may be dismissed 
 from consideration further than to state that if a foreign-body endoscopy cannot 
 be done carefully it had better not be done at all.
 
 ILLUSTKATIVK CASES OF ENDOSCdrV I'uk l-dKKTC.X BODIES. 
 
 40S 
 
 Fig. .-^-o. — Radio^raiilis, lateral and anttro|iostcrior, showing tack in left main 
 brnnchiis iif a lioy of dt-vcn years. Tack removed by oral bronchoscopy witlnnit anes- 
 thesia. (Radio.uraphs made by Dr. George VV. drier. Author's case.^
 
 404 Il.Ll'STRATlVU C.\Si;s 111" IvMlOSCOPV I'OR I*nRKl(;N liODIKS. 
 
 Fig. 371. — Radiographs, lateral and anteroposterior, sliovving tack in loft main 
 bronclui? of a boy of eight years. Tack removed by oral bronchoscopy without 
 anesthesia. (Radiographs by Dr. George \V. Grier. Author's case.)
 
 II.I.USTKATIVl-; CASi:s Ol-' KNDOSCOI'V I-IIR I'ORIUCN HODIIIS. 
 
 405 
 
 Fi(-. T,~2. — Aliscess in n^ilu lun.tj c,[ a lju\ j_j nKnuli- uUl. The ])camil, wlikMi 
 caused the abscess, docs not sliow. Peanut removed and abscess evacuated by oral 
 bronchoscopy without anesthesia. Shadow strengthened f(ir photo-cngravinR. 
 ( Autlior's case.)
 
 406 
 
 ILLl'STRATIVE CASES OF ENDOSCOPY FOR FOREIGN BODIES. 
 
 Fig. 373. — Radiograph showing stickpin in left bronchus of a boy of fifteen 
 years. Pin was removed by oral bronchoscopy. Radiograph made Ijy the roent- 
 genologist of the German Hospital, Philadelphia. (.Author's case.)
 
 ILLUSTRATIVE CASES OE ENDOSCOPY lOR FOREIGN BODIES. 407 
 
 Fig. 3-4,— RadioKraplis, lateral ami aiUerupublerior, sliowiny shawl pin in the 
 left main bronchns (head in upper lobe hroncluis) of a girl of twelve years. Re- 
 moved by oral bronchscopy. (Radiograph made by Dr. George C. Johnston. Au- 
 thor's case.)
 
 408 
 
 ILI^USTKATIVK CASl';s Ol" ICNDOSCOPY FOR l-NJRlCli'.N HODlliS. 
 
 Flu. ,^75. — Radiograiihs, showing pin in rij;lit iironchiis of a boy aged four 
 years. Pin removed by oral bronclioscopy. (Radiograph by Ur. Russell H. Boggs) 
 Pin shadow strengthened for photo-engraving. (Author's case.)
 
 ILLUSTKATI\-|-; CASKS ni' KM'.OSCOPV KOK I-HKICIGN BOUIKS. 
 
 4UU 
 
 Fk;. 37(>. — RadioLsrapli sliowinj; slmc Imllon dmly iiictal part dense cnoiigli l'< 
 show) in left main 1)roni-hus of a girl of seven years. Distortion gives appearance 
 of median position. J-eft Inng atelectatic. Compensatory emphysema of right hmg. 
 Bntton was aspirated three months previonslv. Removal hy oral hronchoscopy 
 without anesthesia, a hook being inserted in the eye of the button. ( Radiograpl 
 by Dr. George C. Johnstin. .\iithor's r:uc )
 
 4J0 ILLUSTRATIVE CASES OF ENCOSCOPY FOR FOREIGN BODIES. 
 
 Fig. 377. — Radiograph showing pclil)le in right bronchus of a girl eight years 
 of age. Removed by oral bronchoscopy. (Radiograph by Dr. George C. John- 
 ston. Author's case. )
 
 ILLUSTRATIVK CASES OF KNDOSCOPY FOR FOREIGN BODIES. 411 
 
 Fig. 378.^Foot of alarm cltuk in left lironcluis of child of four years. Present 
 25 days. Pneumonic consolidation of left lung. Intruder removed by oral bron- 
 choscopy. Radioifrajib one month later showed lung normal. (Radiograph by 
 Dr. George C. Johnston. Author's case.1 
 
 F'G. ^7')■ — Collar liuttnn in c-supbiigus of infant twi'lvo months old. Removed 
 by specular esophagoscopy. ( Radiofiraiiji by I'r. (ieorgc C. Johnston. .\uthor's 
 case.)
 
 412 ILIvUSTRATI\'l': CASnS OF liNDOSCOPV I'dK FORKIGN BODIi:s. 
 
 Fig. 380. — Staple (duuble-pointed tack) in 
 stomach, endoscopically, turned and removed. 
 Boggs. Author's case.) 
 
 csiipha);iis. Intnukr 
 (Radiograph by Dr. 
 
 passed into 
 Russell H.
 
 ILLUSTRATIVE CASKS OF KNDOSCOPY I'OR FOREIGN BODIES. 
 
 413 
 
 Fig. .?8i. — Fiii>;cT riiiy in csopliayiis, ahinc hrDiicliial crossing, of a child of 
 ten months. Ut-movcd hy oral csopha.uoscory without anesthesia. (ka<hogra|)h hy 
 Dr. rviissell H. l'.o«','s. Author's c;isf.)
 
 414 ILLUSTRATIVE CASES OF ENDOSCOPY FOR FOREIGN BODIES. 
 
 Fig. 382, — Radiograph showing button ni esopliagu^ of infant sixteen months 
 old. Removed by specnlar esophagoscopy without anesthesia. (Radiograph by Dr. 
 King. Author's case.) 
 
 Fig. 383. — Radiograph showing coin (Enghsh half-penny) in esophagus of a 
 girl five years of age. Removed by specular esophagoscopy without anesthesia. 
 (Radiograph by Dr. George W. Grier. Author's case.)
 
 ILLUSTRATIVE CASES OF ENDOSCOPY FOR FOREIGN BODIES. 
 
 415 
 
 Fu;. 384. — Radiograpli showiiiy cuin (Canadian twciitj -five cent piece) in tlic 
 esophagus of a child of two years. Coin removed by esophagoscopy. (Radio- 
 graph by Dr. Russell H. Boggs. Author's case.) 
 
 Fig. 385. — Radiograph showing fragment of hone in the trachea of a woman 
 of 39 years. Bones are not likely to show in an anteroposterior view and this 
 radiograph shows how readily a bone low in the neck might be missed in a 
 lateral radiograph. Bone removed by oral bronchoscopy. (Radiograph by Dr. 
 George C. Johnston. Author's case.)
 
 41 G ILLUSTRATIVE CASr-S OF ENDOSCOPY FOR 1-OREIC.N BODIES. 
 
 Fig. i86. — Radiograph sliowing gold locket in esophagus of a girl of 2;/^ years. 
 Locket removed hy esophagoscopy witliout anestliesia. (Radiograph by Dr. George 
 W. Grier.)
 
 ILI.USTKATIVl' CASKS OF ENDOSCOPY FOR FOREIGN' BODIES. 
 
 417 
 
 Fic. 387. — kadiiigrapli showing artihcial dciitiirf in tlie esophagus of a man 
 aged thirty years Removed 'ly t sophagoscopy under ether anesthesia. (Radio- 
 grapli hy Dr. Russell H. I'.oirgs. Author's case.)
 
 418 
 
 ILLUSTRATIVE CASES OF ENDOSCOPY EQR FOREIGN BODIES. 
 
 Fig 387a. — Button with projecting rigid pin in the esophagus of an infant of 
 2'/2 months. Removed hy esophagoscopy without anesthesia. Laceration of esopli- 
 agus prevented hy the method iUustrated in Fig. 209 (Author's case.)
 
 II.LrSTKAIIVE CASES OF ENDOSCOPY 1-OK l-ilKKICN i;iil)li;s. 
 
 41!) 
 
 f 
 
 k 
 
 Fui. .^87!). — Kadiiii^rapiis slio\» iiii; a dental roul-caiial liruach in a small pos- 
 terior branch of a larger posterior branch of the inferior-lobe bronchus of a man 
 of ^g years. The foreign body is seen just above the dome of the diaphragm in 
 the anteroposterior radiograph, though really in the part of the lung down back ot 
 the dome as shown in the lateral radiograph. Removed through the mouth by 
 bronchoscopy under local anesthesia. This is the lowest position from which a 
 foreign body has ever been removed by brimchoscopy. The full length of a 40 cm. 
 bronchoscope was barely sufficient to reach it ( .Author's case.)
 
 CHAPTER XXII. 
 
 Benign Growths in the Larynx. 
 
 The general subject is covered so thoroughly in books upon the 
 larynx that extensive consideration here would be out of place. Only 
 some phases of the subject which ha\e a particular bearing <in endoscopic 
 surgery will be considered. The endoscopic appearances are similar to 
 those by the indirect method except as modified bv the point of view as 
 explained in Chapter \'II. In all ailults careful clinical study by the in- 
 direct method should precede direct laryngoscopy. 
 
 Graiiiiloiiiata in the larynx, while not true neojilasms, in some in- 
 stances need to be dealt with as such, by extirpation. 
 
 Vocal nodules, while not true neoplasms, arc occasionally so stub- 
 bornly resistant of other methods of cure that surgical measures are 
 needed. When ver\- ])rominent thev may be excised under local anes- 
 thesia. Should cocaine cause so much shrinkage as to make accurate ex- 
 cision impossible, general anesthesia will be required. The author has 
 had excellent results in the treatment of sessile vocal nodules by touch- 
 ing them with a fine galvano-cautery point as recommended by Wylie. 
 Sir St. Clair Thomson favors this method in exceiJtional cases, but points 
 out that extreme dexterity is rec|uisite, a caution that is particularly force- 
 ful as we are, in most instances, dealing with a patient to whom the 
 voice is a valuable asset. A form of vocal nodule seen in children and 
 known as "screamers nodes" (Dan McKenzie) may be excised as ad- 
 vised by .\lbrecht ( Ilib. 1 I ). Fibromata, while possibly of infiamniatury 
 genesis in some instances, are clinically true neoplasms, .^s a rule di- 
 rect excision is not followed l)y recurrence if a goodU- portion of basal 
 tissue is removed. A typical case of small fibroma is illustrated in Fig. 
 79. They are, as a rule, best dealt with by the tissue forceps. Fig. 35. 
 They may be sliced off with the Katzenstein guillotine but the author's 
 personal preference is the tissue forceps mentioned because any desired 
 ])ortion of the normal base can be included in the excision. .\t times a
 
 nKNic.N '.•.uovvriis i.n Tin-; larynx. 421 
 
 small granuloma may aiJjJear as the healing granulations organize and 
 mav persist for a few weeks or even months, simulating recurrence. So 
 long as it does not increase in size, excision is not necessary. \ ery large 
 fibromata may be e.xciscd with the basket punch forceps. Fig. :5(;. If so 
 large that the base cannot l)e seen they may be amputated with the snare 
 (Fig. -11), and then the base may be cauterized galvanically. or as the 
 author prefers, excised with forceps. The galvano-cautery is especially 
 useful in destroying the basal vessels of fibro-angiomata. John A. 
 Thompson (Bib. .547) reports an interesting case of removal of fibroma 
 1x1 J4 inches (2.")x:52 mm.) in size, springing from the upper orifice of 
 the larynx. 
 
 The depth of removal of benign growths is closely connected with 
 the tendency to recurrence of the particular growth, and some informa- 
 tion as to this tendency is obtainable from general laryngeal literature. 
 Benign growths repullulale on the surface and do not infiltrate. There- 
 fore, a less amount of normal is needed than in malignancy. Cystomata 
 have 'icen known to get well after galvano-puncture or excision of part 
 of the sac. In the author's experience recurrence can be avoided with 
 certainty only by complete extirpation of the sac. The same is true of 
 adenomata. Angiomata, which are usually much more extensive and 
 deeper seated than appears, reciuire deep excision, and the galvano-cau- 
 terv to destroy the vessels at the base, both to arrest hemorrhage and 
 lessen the tendency to recurrence. A diiTuse telangiectasis if requiring 
 treatment may be ])unctured or scarified at a number of sittings with the 
 galvano-cautery. Lymphoma, enchomlroma and osteoma, if small, may 
 be excised with the basket ])unch forceps (Fig. 31!), taking as much of 
 normal base as ])ossible without risk of stenosis. Myxomata, other than 
 myxomatous degeneration of fibromata is very rare and there are no 
 data on which to base a rule as to depth of excision necessary to prevent 
 recurrence, Lipomata are also very rare. .An interesting resume of the 
 subject will be found in the article by (loldstein (Bib. 171 ). iMoni the re- 
 search there reported it is clear that to avoid recurrence it is necessary 
 to remove thoroughly every vestige of the growth. Thyroid gland tu- 
 mors from aberrant islands of thyroid tissue do not reipiire very radical 
 excision of normal base but should be removed as completely as pos- 
 sible. An excellent article is published by Wells ( I'ib. .")Sii). The fpies- 
 tion of the advisability of merely slicing olT small benign tumors on the 
 vocal cords or in the neighborhood of the arytenoid joint, and deferring 
 more radical removal of the base until the growth demonstrates a tend- 
 ency to recurrence is discussed under iia])illoma. The technic of direct 
 removal of benign growths will be found in Chapter \'ll and special at- 
 tention is called tr) ibe author's method of operating at the side of the
 
 423 HHNir.N GROWTHS IN THE LARYNX. 
 
 tongue instead ;if o\er the doi>nm. Attention is also cal'ed tn the recent 
 development of suspension laryngoscopy, the details of which, I'rof 
 Killian, the originator, has honored us all by describing in a separate 
 Chapter (VIII). Lynch has devised some excellent instruments for 
 suspension work. As stated by Sir St. Clair Thomson (Bib. 539) external 
 operation is unheard of in the treatment of simple laryngeal neoplasms 
 in adults and should be resorted to only when an expert has failed /rr 
 riiis iiaturales. 
 
 r.\I'II,LUXI.\TA C)l* THlv L.\RYNX IN CHILDRF.N. 
 
 Of all benign growths in the larynx papilloma is the most frei|uent. 
 It may occur at any age of childhood and may even be congenital. The 
 author has seen one case in which it was undoubtedly congenital and one 
 in which it was probably so. Both cases follow : 
 
 Congenital papilloma of the larynx. A male infant, two months 
 of age had had a croupy cr)- and stridor without cyanosis since l>irth. 
 It suddenly developed a marked increase in the stridor, with dyspnea 
 and cyanosis. The autb.or was called, but the child was dead when he 
 arrived. Post mortem examination showed a paiulloma on the left cord 
 near the anterior commissure. It did not seem sufficiently large to ac- 
 count for death b\- obstruction even allowing for shrinkage, though the 
 symptoms as described by the parents denoted obstructive dyspnea. The 
 thymus and other viscera were normal. Doubtless indrawing of the 
 upper laryngeal aperture contributed ; possibly spasm did also. 
 
 In the second case the author was called for direct examination of a 
 new born male infant that was cyanotic and showed deep indrawing at 
 the supraclavicular and suprasternal notches. Direct laryngoscopy, with- 
 out anesthesia, revealed a large papilloma occupying almost the entire 
 upper laryngeal orifice. It was immediately excised and then the origin 
 was seen to be single on the right cord near the anterior commissure. 
 The patient was about si.x hours old at the time of operati(jn. It was 
 seen once subsequently (by Dr. L. C. Manchester) about three months 
 after operation. There was then no sign of recurrence, but this is not 
 certain evidence that recurrence did not lake place later. 
 
 Methods of treatment of papillomatu of children. A sharp distinc- 
 tion must be made between papillomata of adults and of children because 
 of the greater difficulty in curing the tendency to recurrence in the latter. 
 In dealing with i)apillomata of the larynx in children, it is well to re- 
 member that we have two classes of case. Those in which the growth 
 gets well either si)ontaneously or with slight treatment, surgical or other- 
 wise. Second, those which are not readilv amenal:)le to anv form of
 
 BKNIGX C.KdWTIIS IN THE LARYNX. 423 
 
 treatment and require persistent treatment of recurrences. Sweeping 
 deductions should not be made from reports of isolated cases, even if 
 observed for a year after o;)eration, because of the different behavior of 
 difTcrent cases as to recurrence, and cases reported immediately after 
 operation are valueless statistically because of the large percentage of re- 
 currences. If we are ever to arrive at final conclusions, all the cases 
 seen by each observer must be reported, and the report should not be 
 made until after at least one year's observation of cure. 
 
 There are nine methods i<\ treatment to Ijc considered. 
 
 1. Endolaryngeal applications. 
 
 2. Tracheotomy with subscc|uent rest of the larynx for a period 
 of years. 
 
 3. Thyrotomy with radical extirpation of the growth. 
 
 4. Fulguration. 
 
 "i. Radium and mesolhurium. 
 
 6. Roentgen radiotherapy. 
 
 7. Endolaryngeal operation. 
 
 8. A comljinatinn of two or more of the above mentioned methods. 
 
 9. Laryngostomy. 
 
 Delavan established the value of alcohol applications in some cases. 
 It is usually best to start with dilute alcohol, say about 50 per cent and 
 increase the strenglii until absolute alcohol can be used. The applications 
 may be made by the indirect method, using the gauze sponges and sponge 
 holder. Figs. 2.") and 2(>. No anesthetic is needed. The sponges should 
 not be dri[)ping. Spasm usually subsides quickly but this or any other 
 method should not be used without previous tracheotomy if there is 
 stenosis. E. I.. Jones has had excellent results from organic salicylic 
 acid saturated solution in alcohol. 
 
 Tracheotomy for papUltniuita. The beneficial effect of tracheolotny 
 has long been noted. It is \ery marked in some cases, disap[)ointing in 
 others. Ai)art from its beneficial effect it should always be done as soon 
 as the child develops noisy breathing and restlessness at night. Severe 
 dyspnea with indrawing of the supraclavicular and sternal fossae and 
 epigastrium should not be awaited. The rule should be, here as else- 
 where, to do the tracheotomy always early rather than late. Many cases 
 are in extremis when they arrive. Hallenger reports the death of a child 
 with pai)illoma of the larynx on the way to the hospital, and a similar 
 experience is known to almost every laryngologist. In cases of i)apillo- 
 mata of large size, completely, or almost completely, obstructing the 
 lumen of the trachea, it is necessary to proceed with extreme caution with 
 the direct laryngoscopy, and not to unduly prolong the examination, be-
 
 424 BENIGN C.KOWTIIS IN THE LARYNX. 
 
 cause engorgement of the papillomata may very much increase their size 
 and obhterate what little lumen remains. It takes but a moment, with- 
 out any anesthesia, to get a good view of the larynx ; but failing in this, 
 the operator who suspects papilloma in any extremely dyspneic case, is 
 perfectly justified in doing the tracheotomy first and making the diagnosis 
 as to the exact condition afterward. The state of affairs in regard to 
 tracheotomy for dyspnea is precisely the same as gastrostomy for dys- 
 phagia. 
 
 Thyrotomy for papilloiuata. I'.efore the days of direct laryngos- 
 copy the author tried thyrotomy for the removal of papillomata in chil- 
 dren. The recurrence was so prompt that the author abandoned thyrot- 
 omy for this purpose and has rejieatcdlv spoken against it. He is de- 
 lighted to find that his opinion in this respect coincides with that of the 
 greatest living authority on the larynx. Sir Felix Semon, who mentions 
 one case (Bib. 511) in which seventeen thyrotomies were performed on 
 the same patient with failure to cure. A great deal of damage may be 
 done to the larynx by repeated thyrotomies. and intractable stenosis from 
 deformity is almost certain to result. In these days of quick and thor- 
 ough removal by direct laryngoscopy, there is rarely justification for doing 
 thyrotomy, because endoscopic removal is just as thorough, no more likely 
 to be followed by recurrence and repeated endolaryngeal removals are 
 harmless if carefully done. 
 
 fiilguration for papillomata. Harmon Smith ( ISib. 470) has had 
 very satisfactory results with fulguration for papillomata in children and 
 his interesting article should be read for details of the technic. 
 
 Radium for papillomata. Thomas J. Harris (Bib. Iil4 ) reports 
 very favorable results from the use of radium in one case of his own 
 and in twelve cases in the hands of Abbe. Culbert. Freudenthal, Polyak, 
 Ivillian and Alazzochi. As stated bv tlarris, imi mgm. of radium 
 
 should be applied. \\ eaker applications probablv irritate, ihe duration 
 of each application, of course. de]iends upon the quantity of radium in 
 the container. \\ ith loo mgm. of radium element, or its equivalent in 
 liromide or other salt, a duration of 20 minutes is probably sufficient. 
 From two to ten sittings are usually necessary. .A single application in 
 some instances has caused a marked diminution in the growth, but recur- 
 rences, as with other methods, will probably require repeated treatments. 
 Some cases do not seem to yield so readily. The future will determine 
 the exact sphere of usefulness, and the dosage and duration of applica- 
 tions. A screening of not less than two mm. of metal and outside of 
 the metal two mm. of hard rubber are essential to protect healthy tis- 
 sues. The radium container should have an eve bv means of which 
 it can be secured in position hv attaching it to the tracheotomic cannula
 
 BKNICN C.KOWI'H;. IN TIIK T.AKYXX. i2'> 
 
 above which it is inserted. The capsule may be hekl in place in un- 
 tracheotomized cases, but the spasm excited rec|uires a small container 
 with suHicient screenintj and dosage. Mesothdiium has been used by 
 Killian. 
 
 Endolaryuiical extirpation of papUlomata in children is practically 
 limited to the direct method. Xo one who has ever worked by the direct 
 method would think of i^oing back to any indirect attempt in children, 
 necessitating as it usually does, general anesthesia. To work with the 
 mirror in an adult under local anesthesia is difficult enough, but to work 
 with a child under a general anesthesia with the mirror presents diffi- 
 culties that are almost insurmountable, to say nothing of the extreme 
 danger of anesthesia in this class of cases. Worse yet is. as was done in 
 the old days, a finger-guided forceps operation. As elsewhere stated 
 no anesthetic whatever, general or local, is needed in the extirpation of 
 papillomata in children. If. for any reason, a general anesthetic is used. 
 it should be only in the tracheotomized cases because of the danger in 
 dyspnea in untracheotomized patients. If a general anesthetic be used 
 it is absolutely needless to add th.e risk of a cocaine application in a 
 child. As a matter of fact a general anesthetic has only one excuse, and 
 that is to lessen the spasm of the larynx in order to enable the operator 
 more accuratelv to ajijfly his forceps. With increased practice the oper- 
 ator will find that even for this purpose it is unnecessary. There is a 
 peculiar sensation of softness to papillomata that, once recognized, is un- 
 mistakable and that w ill prevent the operator from forcibly removing any 
 tissue other than papillomatous because of the firm resistance felt when 
 normal tissue is grasjied. In other words, the operator must train him- 
 self to apply just the amonm uf |>ressure to his forceps which is neces- 
 sary to remove papillomatous tissue, but which will not bile into normal 
 tissue. It goes without saying that such a degree of tactile sensibility 
 can only be possible with extremely delicate and easy working forceps. 
 Heavy handled, spring opposed, clumsy instruments will bite out any- 
 thing, even cartilage, before any useful sensation is communicated to 
 even the most delicate touch, because delicacy is destroyed by the op])o- 
 sition of the spring and the crude mechanism. Some authors advise 
 against removal of pai)illomata in children during the stage of growth, 
 ])rcferring to do a tracheotomy and wait for a ])eriod of recession of the 
 growth before extirpation. The dilliculty is, as Sluckv puiiUs niu. in 
 determining tlie period of recession. 1 'apilloniala should always be re- 
 moved and the patient cured of recurrences, because, contrary to state- 
 ments sometimes made, a child is not safe with only a tracheotomy can- 
 nula U|]on which to depend for air. unless under constant care of a phy- 
 sician and an experienced tracheal luirse. Accidental removal of the
 
 42(< BKNIGN GROWTHS IN" THE LARYNX. 
 
 cannula following indrawing closure of the fistula has caused the death 
 of many children. Others have died of occlusion of the cannula with 
 secretions, dressings, granulations and papillomatous masses. In all 
 cases of papilloma of the larynx the subglottic trachea should be in- 
 spected not only once but at e\ery removal of the supraglottic papillo- 
 mata. Many endoscopists have wondered why they cannot decannulate 
 a papilloma case after removal of apparently all the growth. The rea- 
 son is that the region between the glottis and the tracheal wound is full 
 of papillomata. For this removal a bronchoscope may be inserted through 
 the glottis, or a bronchoscope not slanted at the end ma}- be used for 
 supraglottic tracheoscopy. The author uses the direct laryngoscope and 
 the tissue forceps, Fig. oT). In some cases the tracheal papillomata can 
 be removed through the tracheal wound. Often it is impossible to dis- 
 tinguish between granulation tissue and true papillomata except by 
 biopsy. It is not necessary, however, clinically to distinguish as it is a 
 good thing to remove granulations which are so exuberant as to simulate 
 papillomata. The technic of direct laryngeal extirpation is considered 
 in Chapters \'II and \'III. The special infant-size slide speculum is best 
 for infants under 6 months. 
 
 The antlior's method for papillomata in children. The author has 
 had best results from a combination of the alcohol application of Dela- 
 van between excisions by the direct method, and with tracheotomy in all 
 cases that persistently repullulate. No tracheotomy is done at first, if the 
 growth is small and especially if single (they rarely are), because there 
 is a chance of cure by a few extirpations or in a few instances even by a 
 single extirpation. If the child is slightly dyspneic the obstructing part 
 of the growth is first removed directly without anesthesia, general or 
 local, and then the remaining fungations are extirpated at a number of 
 brief seances. The alcohol applications are not used in these cases. 
 When repullations and growths in new locations demonstrate an in- 
 tractable case, it is treated the same as a dyspneic case. If the child is 
 very dyspneic when first seen the author does a tracheotomy, waits a 
 week or ten days, and then proceeds with the extirpation without anes- 
 thesia and the alcohol after-treatment. The child is kept in the hospital 
 under the watchful care of special tracheal nurses. If the growths are 
 subglottic, reactionary edema of this region is very apt to rec|uire tracheot- 
 omy after extirpation, and therefore subglottic cases, whether dyspneic 
 or not, are tracheotomized unless the growth is single and very small. 
 The effect of the alcohol and the stiperficial cicatrices is to make an un- 
 favorable soil for the growth of papillomata which, in a sense, resemble 
 \enereal warts. CiaKano-cauterization is used in the worst cases to de- 
 stroy the bases and to promote superficial cicatrices. The eflicacy of re-
 
 UKNIGX C.KnWiIlS IX THE LARVXX. 427 
 
 moval and the post oi)erative jqjplication of alcohol has been corroborated 
 by Stucky (Bib. ■'Al) and a number of other laryngologists. Its great- 
 est drawback is the length of time rec|uirc(l for cure in the very stubborn 
 cases. But it will eventually cure almost all cases, and as the extirpations 
 without anesthesia are not painful t the children do not even cry after the 
 tirst few treatments) the author feels justified in adhering to it uniil 
 some equally effective and more rapid method is sufficiently tested. 
 
 Lar\nuostomy. When all else fails in the few most stubborn cases, 
 laryngostoniy m.ay be reported to. Lining the larynx with ejiidermal 
 epithelium makes a soil upon which papillomata will not grow, notwith- 
 standing the fact that, as occurred in one case of the author, a t\pical 
 pa[)illoma identical liistologicallv with the laryngeal growths occurred on 
 the normal skin of the neck The after-treatment of laryngostoniy ex- 
 tends over months, l/nlike thyrotomy, it does not produce stenosis by 
 causing deformitv of the larynx. Cases stenosed by injudicious thyrotomy 
 are curable by laryngostomy, which are the only papillomatous cases in 
 which the author advises laryngostomy. 
 
 l'.\l'II.l.OM.\T.\ IX THE L.\RVXX OF .\DULTS. 
 
 Papillomata in adults are, on the whole, much more amenable to 
 treatment than similar growths in children. Tracheotomy is very rarely 
 re(|uired. and recurrences are slower in development. Many more cases 
 are cured by a single extir[>ation and recurrences at new sites are not so 
 conmion. In some instances the growths may be single, relatively quite 
 librcius and pechmculatcd. This form is beautifully illustrated in an in- 
 teresting article by Loeb (Bib. •'STSj. 
 
 In all forms of papillf)mata in adidls operative remoxal is so satis- 
 factory that tlu-re is little temptation to try other methods. 
 
 Pcf^th of removal of popUlomata. Should the growth be simply re- 
 moved from the surface? ( )r should the basic normal be removed? And 
 if so, how widely? To determine this point clinically, it was necessary 
 to know whether the reapi)earances of papillomata are repullulations at 
 the site of removal or whether fresh areas became the site of new growths. 
 To determine this i>oint accurate drawings were made by the author, and 
 it was discovered that in eighteen cases nin of twenty there was no re- 
 currence at the site of removal if about ;! millimeters depth of nor- 
 mal tissue was removed. That is, there was no recurrence in the scar. 
 In iwo cases the recurrence was so close as to be doubtful. On the 
 nlher hand, in this same series of twenty cases in locations where the 
 growths were sinijily removed from the surface, twenty out of twenty 
 instances recurred. In another series of eighteen cases in which surface 
 remn\al was done, papillomata ap|)eared in a greater number of new lo-
 
 428 F.KNir.X GROWTHS IN THK I.Ai;Y.\X. 
 
 cations after operation. It still remains a question whether the less tend- 
 enc}' to recurrence after removal with a normal base was due to extir- 
 pation of every vestige of growth, or whether it was simply due to the 
 fact that scar tissue is a bad soil for papillomatous growth. Clinical ob- 
 servation shows that papillomatous growths in the larynx or trachea 
 usually do not spring from a tirm thick scar. The author has noted the 
 avoidance of scars by papillomata when extending down the trachea 
 from the larynx toward the tracheotomic wound. In the author's opinion, 
 when the growths are situated on the cords it is usually better to re- 
 move them with a very scanty base, telling the patient of I'robable re- 
 currence. If there is a recurrence, slightly more radical remo\al is in- 
 dicated, but under no circumstances should reckless or radical extirpa- 
 tion of normal tissue be indulged in. Cicatricial stenosis and prolonged, 
 possibly permanent, impairment of the voice may result. In case of re- 
 movals in the neighborhood of the arytenoids, great care must be used 
 to avoid impairment of the laryngeal motility. The growths should 
 everywhere be nipped off with only a small normal base and recurrences 
 should be similarly nipped in the bud. Alcohol applications are useful. 
 In contrast with the prompt and excellent results obtained in most cases, 
 a very stubborn case is occasionallv encountered which simulates the 
 conditions found in children. The following is an example : 
 
 A single woman, aged twenty-five, was sent to the author by Dr. I. 
 I!. Reed for loss of voice of three months' duration following two months 
 of hoarseness. Within the last two weeks dysjinea had been developing 
 and examination by the indirect method re\ealed a large mass of papil- 
 loma occupving the entire right half of the larynx with more masses on 
 the epiglottis and high up on the left ventricular band (A. Fig. 7I>)- 
 These were remoxed giving complete relief from the dyspnea and permit- 
 ting some phonation. The patient was not seen for some time and re- 
 turned extremely dyspneic. A recurrence of larger size than the original 
 growth was foimd and many new locations were invaded, .\fter remov- 
 ing the upper growth it was found that the pa])illomata had sjirung up in 
 the trachea which at the first operation was entirely free. I'atient work 
 and many sittings were necessary until finally at the end of sixteen 
 months the patient was entirely free from any sign of recurrence and has 
 remained so since. A period of four years having now elapsed, the i'a- 
 tient may be called cured. The vocal results are excellent, the patient's 
 voice perfectly normal for speaking and quite a good singing voice has 
 also returned. This the author regards as due to the careful avoidance 
 of injury to any of the submucosal tissues. .Vecessarilj- a considerable 
 amount of the mucosa itself was removed with the base of the papilloma.
 
 HKNIGN' CKowi'iis IN 'riii: i.akvnx. 42it 
 
 Plastic opciation favoriiui the dciclopmcnt at adventitious vocai 
 hands. Some of the cases of papillomata from frc(|uent accidents asso- 
 ciated with iinHrect operations come in with the cords entirely destroyed 
 and the larynx badly damaged. If there is motility in the arytenoids there 
 is good hope of repair by careful work. The following case is an ex- 
 amiiie : 
 
 A man, aged twent\-five. had been under the care of one of the old- 
 est laryngologists in the country for two and one-half years for hoarse- 
 ness. During this time a number of indirect operations upon the larynx 
 had been done for renio\al of papillomata. The operations were difficult 
 because the patient was insusceptible to anesthesia In- cocaine, lie was 
 
 Fig .388. — IllustraliiiK operation favoring formaiion of an ailvi-ntitious vocal 
 band in a man aged twcnt.v-five ycar.s. .A. Papilloma and Kranulation tissue with 
 destruction of the vocal cords and the lip of one arytenoid eminence as the result 
 of indirect operation. B. Cured of papilloma after many direct extirpations under 
 local anesthesia. A web extended across the larynx from the right side from the 
 neighborhood of the site of the original cord to the remnant of the ventricular 
 band of the left side. Dotted line sliows the position of incision for a plastic to 
 assist in forming an adventitious band on the left side. C. Three months later 
 the triangular mass of cicatricial tissue shown in 11 has become stretched out into 
 an adventitious band. 0. Three months later entire stretching out, absorption 
 and disappearance of the elevation, resiillinir in the normal larynx \\ith good voice. 
 From a crayon drawing by the autlior. Patient referred to llie author by Dr. 
 JaiT;es F. McKernon. 
 
 c()ni])letcly aphonic and could mil. with the most vinlcnt ellorts, phonate 
 in the slightest degree. In this condition be a|)plied to Dr. James 1". 
 McKernon of Xcw \'ork City who found the larynx filled with a mix- 
 ture of papillomatous and granulation tissue. Xo sign of a cord was 
 present (A, Fig. :!S,S). Part of the arytenoid eminence was gone and its 
 place was taken iiy a fungating luass of granulation. A i)art of each 
 ventricular band was gone and. granulations covered both bands. On at- 
 tempted i)honation jjoth arytenoids moved, but no sign of aiivthing re- 
 sembling a vocal cord resultecl finni the movement. Dr. McKernon re- 
 ferred the case at once to the author for treatment. Lnder local anes- 
 thesia, the author removed all the tissues that looked pai)illomatous and
 
 4:30 BKNir.N C.ROWTHS IN 'J' 1 1 1- LAkVNX. 
 
 some of the most exuberant granulations. At intervals during the fol- 
 lowing year recurrences of papillomata were removed, until at the end 
 of sixteen months the patient returned after a three months' interval 
 completely free from granulation and recurrences. A web extended 
 across the larynx oljliterating the entire anterior half as shown at B, 
 Fig. 388. The author then did a plastic operation by making an incision 
 along the dotted line marking out a cord from the cicatricial tissue, the 
 incision extending from the arytenoid clear out to the perichondrium an- 
 teriorly. The tissue seemed under tension and the triangular flap after 
 the incision hung almost altogether over toward the patient's left side 
 and away from the adventitious band on the patient's right. The inci- 
 sion was made with the laryngeal knife, Fig. S-"). At the end of three 
 months this flap had flattened out and the action of the arytenoid on the 
 cicatricial tissue had formed a verj- fair adventitious band with a projec- 
 tion simulating a vocal nodule (C). The first impulse was to remove 
 this, but believing that it would furnish tissue to be extended by the 
 combined effects of cicatricial contraction and the arytenoid action noth- 
 ing was done with it. Three months later the patient returned and ex- 
 amination showed the condition to be as shown in 1!. The patient at this 
 visit reported that six weeks before, he had astonished himself and his 
 family by speaking. Dr. AIcKernon, who was kind enough to again 
 examine the patient, in the condition shown at D, stated that he thought 
 the results quite a clear indication of the possibilities of work by the di- 
 rect method. The patient is now able to do his part of the shouting in 
 a football game. The voice is deep and somewhat rough ; but, judging 
 by similar cases, it will become smoother in time. 
 
 For the success of the operation it is necessary to wait until the 
 cicatricial contraction has put the scar on tension, otherwise the incision 
 is apt to heal and unite its two edges. On the contrary, if there is ten- 
 sion, as in this case, the incision will gape so widely that there will be no 
 chance of its adhering and the subsequent cicatricial contraction will tend 
 to widen the gap instead of to narrow it. Another factor in the success 
 of this kind of a case is not to remove tissue ; differing in this respect from 
 cases of redundancy such as shown in Fig. 15, Plate I. The adventitious 
 bands are always thick at first and become thinned down as the cicatricial 
 tissue contracts and as the effect of the traction of the arytenoid begins 
 to become manifest. The author has used similar operations in cicatricial 
 larynges following conditions other than [)apillomata, though not always 
 with the same success as in the case above mentioned.
 
 CHAPTER XXIII. 
 
 Benign Growths Primary in the 
 Tracheobronchial Tree. 
 
 Bcn'ujii f/roictlis f^riiinirx in llir trachea and bronchi. Extension of 
 papilloniata from the lar)-nx into the cervical trachea, especially about 
 the tracheotomy wound is of relatively common occurrence, and that 
 form of tracheal benignancy ban already been considered in its proper 
 place, with laryngeal growths. L'nder the present heading will be in- 
 cluded only the primary neoplasms of the tracheo-bronchial tree. I'aijil- 
 lomata and fibromata are the most fre(|uent of the benign tumors in the 
 trachea. .Aberrant tlnroid, lipomata. enchondromata. chondrosleomata, 
 adenomata and lipomata occur in the trachea, but not all of these have 
 been reported to have been discovered endoscopically. When the au- 
 thor encountered the first case of primary tracheal benign tumor in the 
 early days of bronchoscopy (Ijib. 3(19) he supposed that such tumors 
 were not uncommon but simply undiscovered. In the nine years that 
 have elapsed since that time he has seen but one other benign true neo- 
 plasm in the tracheo-bronchial tree, though he has seen a number of be- 
 nign "tumors"' not truly neoplastic. 
 
 Papilloma primary in the trachea. Mann reports two very inter- 
 esting cases of this kind diagnosticated and removed bronchoscopically. 
 Other interesting cases are reported by von Schrotter and Spiess. The 
 author's previously reported case is as follows: 
 
 A girl, aged four years, was brought to the Eye and Ear Hosi)ital 
 Dispensary for cough which had persisted for two months since "strang- 
 ling" on a crumb of bread that "got down the wrong way.'' Radiograph 
 by Dr. Russell H. lioggs was negative. Physical examination by Dr. 
 Brush demonstrated a cooing sound all over both sides of the chest. 
 There was no dyspnea or cyanosis. Thinking of the possibility of a for- 
 eign bodv in the bread, the author passed a lironchoscope and found a 
 small ]iinkisli while mass of tissue about six millimeters in diameter.
 
 432 BENIGN C.RIJWTIIS TKLMARV IX TRACHKOBRONCHIAL TRKE. 
 
 with mammillated surface attached to the left tracheal wall about one 
 centimeter alio\e the biftircation. Thinking of a foreign body granu- 
 loma, the author excised the tissue, leaving a flat surface oozing a trifling 
 amount of blood, but no sign of foreign body. Dr. Joseph H. Barach 
 reported: "Histologic examination of the tissue shows a typical papil- 
 loma which could not be confused, histologically, with a granuloma.'' 
 The child did not return to the clinic. Dr. L. C. Manchester, who kindly 
 went to the child's home to have her brought back to the clinic, failed 
 to convince the parents of the necessity, the cough having disappeared. 
 When seen by him a second time, about three months later, the cough 
 had not returned and there was no cooing sound or other abnormality 
 ai)parent to physical examination. The child was lost to further obser- 
 vation. 
 
 fibroma primary in the traclieo-broHchlal tree. An interesting case 
 of fibroma is reported by Sauer (Bib. .">!.")), occurring in a man, aged 7-i 
 years. The growth produced severe dyspnea and was detached bv the in- 
 sertion of the bronchoscope and was coughed up in two i)ieces. Emil 
 Mayer (Bib. 4iiS) reports the tliscoverv and removal of a soft fibroma 
 from the bronchus of a child bronchoscoped for bronchiectasis. 
 
 The author's case of fibroma is as follows: A boy of Hi years was 
 referred to the author by Dr. Henry Eastman for cough which had per- 
 sisted for six weeks since inhaling an insect thought to have been a fly. 
 'I'lie insect had been coughed up and identified in the sputum a few days 
 after the accident but the cough did not ameliorate. Radiographic ex- 
 amination by Dr. George C. Johnston and physical examination by Dr. 
 Henry Eastman were both negati\e. At bronchoscopy under local 
 anesthesia the author found a smooth, pedunculated and freely movable 
 growth, about six centimeters in diameter attached to the lower margin 
 of the orifice of the left u])per lobe bronchus. Traction with straight 
 forceps demonstrated a firm attachment which was excised along with a 
 liberal amount of base by the tissue forceps ( P'ig. 3.")). There was lilood 
 streaked expectoration for a few days. At bronchoscopy two weeks 
 later there was no sign of recurrence. Dilated ca[)illaries were visible 
 in tlie neighborhood of the site of removal. Bronchoscopv aboiu eight 
 months later showed no sign of recurrence and the boy seemed normal 
 in every way. Histological examination by Dr. lamest W. W'illetts 
 showed the growth to be a pure filiroma of probably slow formation and 
 long standing. 
 
 Enchondroma of the traeheo-hronehial tree. \'on Eicken ( I'.ib. ."iill ) 
 reports the remo\al of an enchondroma of the bn melius liy means of 
 biting forceps.
 
 BENIGN C.ROWTKS rklMARV IN TRACIIKOBRONCHIAL TRKK. 433 
 
 Amyloid tumors of the trachea are reported by Reicli ( IJih. 4(i3). 
 
 Osteomaia of the trachea are re])orted by Mackleston (Hib. 400) 
 and Levinger (Bib. 3-51). 
 
 r.chinococcus of the lung in an isolated focus producing dyspnea was 
 discovered bronchoscopically by Kob and the case is reported by \\ ad- 
 sack (Rib. 32.5 and 587). 
 
 Thyroid tumors. (Benign). While not a true neoplasm, the oc- 
 currence of aberrant thyroid tissue within the lumen of the trachea may 
 be so regarded and should be so treated. The author has had one such 
 case, as follows: 
 
 A woman of 34 years was certain that she had aspirated a fish bone 
 three days before coming to the author. Bronchoscopy revealed a tracheo- 
 bronchitis. Xo foreign body was present, but a small pedunculated 
 tumor was found attached to the left anterior wall of the trachea. It 
 was removed with the tissue forceps. Fig. 3.3, and found by Dr. W'illetts 
 to be composed of thyroid tissue. The endotracheal wound healed in a 
 few days, and eight months later there was no sign of any operation hav- 
 ing been done upon the trachea and the wall seemed smooth and normal. 
 The thyroid gland and its isthmus were in normal position and of about 
 normal size. It seems quite unlikely that the tumor had any connection 
 whatever with the patient's symptoms, though, as mignt nave been ex- 
 pected, the symptoms subsided and probably would have done so with- 
 out operation. .A very interesting consideration of the thyroid gland in 
 its relations to the trachea has been written by Otto Stein (liib. r)()2). 
 
 Granuloma of the trachea, the result of perichondritis, has lieen 
 observed by the author in a number of instances. In two cases it was due 
 to the traumatism of a foreign body aspirated and coughed ui) three 
 weeks and two months respectively after the accident. In the first in- 
 stance, the granuloma was found at bronchoscopy two months after the 
 cougiiing up of the foreign body, and in the second, about four weeks 
 after. In both cases bronchoscopy was done for persistent cough and 
 dyspnea, which led to the suspicion that the foreign body might have 
 been multiple, with consequently one or more still remaining in the air 
 ]iassages. In both instances, removal of the granulation tissue with aj)- 
 plication of argyrol in 3(1 per cent solution, resulted in a cure, only one 
 treatment being necessary in one case and three treatments in the other. 
 A very interesting case of granuloma in the trachea is reported by Sir 
 Robert Woods. Extreme dyspnea nn bnth inspiration and expiration 
 had persisted for two months after an attack of bronchitis. Three bron- 
 choscopic removals resulted in a i)erfect cure. The possibility of a 
 granuloma being tuberculous or luetic must always be kept in mind.
 
 434 BENIGN GROWTHS PRIMARY IN TRACll I'l )BR(>NCIIIAL TREE. 
 
 Symptoms of benign tumors of the trachea. Whether or not cough 
 is a usual symptom of tracheo-bronchial benign tumors, it is impossible 
 to say, because the small number of cases reported form an insufficient 
 basis for deduction, but it seems the most constant symptom. Dyspnea 
 and all of the symptoms of defective drainage of secretions supervene 
 when the growth becomes large enough to be obstructive. Radiography 
 is of service in enchondromata and osteomata, and its routine use in all 
 chronic chest diseases is indicated from many viewpoints. Doubtless the 
 same will be said in the future in regard to bronchoscopy. 
 
 Endoscopic appearances of benign grcn^'tlis. The detection of be- 
 nign growths endoscopically is not at all difficult, but occasionally granu- 
 lation tissue will be removed under suspicion of being neoplastic. As 
 this is good treatment anyway for exuberant granulation, it is the proper 
 course and the microscope can make the diagnosis. Another possible 
 mistake is a small adherent mass of secretion which sometimes simulates 
 a white growth in appearance. The removal of this clears up the diag- 
 nosis. Syphiloma of the trachea, as in the following case, may simulate 
 tumor very closely. A man, aged 40, complaining of severe dyspnea and 
 slight dysphagia, was found to have a sessile tumor projecting from the 
 right posterior wall of the trachea. There was a strong suspicion of 
 malignancy, but as it is the author's rule to apply the therapeutic test 
 to all (|uestionable cases of malignancy no specimen was taken in this 
 case. Foiu- weeks of antiluetic treatment cleared up the tumor com- 
 pletel}'. In another similar case a specimen was removed because of the 
 exceedingly strong suspicion of malignancy. Dr. W'illetts reported the 
 specimen as certainly not malignant and with a strong suspicion of lues. 
 Treatment \eritied the biopsy. Most important of all is not to mistake 
 an aneurysm which is invading the trachea for a tumor. This is perhaps 
 the one mistake which absolutely must not be made. An aneurysm of 
 sufificient size and duration to invade the tracheal wall can be diagnosti- 
 cated by the internist, the fluoroscopist and the radiographer. The en- 
 doscopic appearances of aneurysm are rather of compression than of a 
 neoplasm involving the tracheal wall. The lumen is apt to be more or 
 less scabbard-like in shape. There may not be an abnormal amount of 
 pulsation. The endoscopic appearances of aneurysm are elsewhere men- 
 tioned. 
 
 Brouchoscopic removal of benign groiulhs of the trachea presents 
 but little difficulty if proper forceps are used. The author has had great 
 satisfaction in all sorts of removal of tissue from the larynx, trachea, 
 bronchi and esophagus with the forceps shown in Fig. 3."). They will bite 
 into the lateral wall if the movable jaw be forced toward the wall. The 
 jaw should be set so as to rise, in the normal position of the handle. In
 
 BENIGN C.ROWTIIS TKIMAKV IN TKACHHOBRONCHIAL TREli. 435 
 
 case of large tumors producing great dyspnea quick action may be nec- 
 essary because the dyspnea is apt to be increased by the spasm incidental 
 to the presence of the bronchoscope in the trachea. Under no circum- 
 stances whatever should a general anesthetic be used for such an oper- 
 ation. The larynx may be locally anesthetized and the bronchoscope in- 
 serted with an assistant holding the forceps in readiness for immediate 
 removal as soon as discovered. Of course, the presence of tumor may 
 not be suspected, but in every case of dyspnea the endoscopist should be 
 prepared for every emergency. The risks of removal are ver\- slight 
 so far as hemorrhage is concerned if the growth is small, even if it is 
 angiomatous, provided it is not fungations on an aneurysmal erosion. 
 The blood from a slow oozing will be coughed out. before the clots break 
 down. 
 
 Edi'iihitoiis f'dlypi ill the tn'clu'o-hroncliial tree. Edematous polypi 
 and otb.er more or less tumor-like inflammatory sequelae are not infre- 
 (luently seen in connection with the mixed infections following ulcera- 
 tir)n from maliirnant or other diseases.
 
 CHAPTER XXIV. 
 
 Benign Neoplasms of the Esophagus. 
 
 The author is unable to add anything from personal experience to 
 the single case reported (Rib. ?li9, p. 113). In the author's experience, 
 therefore, benign tumors of the esophagus are among the most rare af- 
 fections. He haa seen a number of cases of edematous polvpi associated 
 with other lesions, benign and malignant, and one without any associated 
 lesions that could be determined at the time of the esophagoscopy. The 
 specimens were reported upon by Dr. Ernest W. W'illets as edematous 
 tissue with more or less fibrous connective tissue, and with a layer of 
 squamous epithelium. These, of course, were not true neoplasms, but, 
 like similar tumors in the nose, were the result of i)rolonged inflammation. 
 The author has also seen a number of cases of granulomata, and in one 
 instance, a mass of scar tissue that resembled a cheloid. A few cases 
 of varicosities resembling angiomata were seen and will be mentioned 
 under Diseases of the Esophagus. Guisez (Bib. 178) mentioned reports 
 of retention cysts by Sappey, Klebs and Zahn ; epithelial cysts by Wyss : 
 congenital cysts associated with tracheo-esophageal fistulae by Eppinger 
 and Petrow ; dermoid cysts by \\'attman ; warts similar to dermal ver- 
 ruccae by Klebs : papillomata by Reher ; fibromata and lipomata by La- 
 boulbene ; myomata by Zenker, I'ichler, Eberth and Blagoviechienski ; 
 adenomata bv \\'eigert and Minski. The references are not given; but 
 presumably the cases were mostly, if not altogether, rejiortcd in the pre- 
 esophagoscopic days from autoptical findings.
 
 CHAPTER XXV. 
 
 Endoscopy in Malignant Disease of the Larynx. 
 
 l''ollo\viiii^ llic initiative ot Sir Felix Scmon and Mr. Ilutlin. tho an- 
 thiir's thyrotomies for intrinsic laryngeal malignancy of small extent 
 have yielded such a large percentage of cures, that he feels that it would 
 be a step backward to attempt endoscopic extirpation. Therefore, in 
 the author's opinion, the usefulness of direct laryngoscopy is confined to 
 diagnosis of the disease, and, e<|ually important, to assist in deciding tlie 
 (|uestion of ojierability. -As urged by Semon no specimen should be 
 taken in a case clinically malignant, unless the patient has already con- 
 sented to operation in the e\ent of biopsic confirmation. This applies 
 with especial force to intrinsic disease. The technic of taking a speci- 
 men by direct laryngoscopy is given in Chapter \TI. T-'articular attention 
 is called to the author's metliod of operating at the side of the tongue in 
 stead of over the dorsum. The autlior has had uniformly good results 
 from bi()|)sy in malignancy since taking the specimens bv the direct 
 nK-tbiid. which is in marked contrast to prior results from the indirect 
 method. C'omplications after taking a specimen are rare if the case is 
 m;dignant. They are the same as might follow anv endolaryngeal o|)era- 
 tion ((|. V. ). In i-ase of a gunnua on the eve of breaking down, the ])rocess 
 m;iy be hasteneil and prompt specific treatment will be necessar\-. 
 
 The decision as to the operability of atiy laryngeal malignancv de- 
 pends u])on whether the ])arty wall is inxuKed or not. !n\dl\ement, no 
 matter how slight, means the patient's chances arc slender, no mallei- 
 how radical the operation, liecause of the free lymi)lialic leakage. The 
 degree of involvement can be determined by clirect laryngoscojiic and 
 esophagoscopic examination of the party wall, on its anterior and pos- 
 terior surfaces. The esophageal s]ieculnm is useful here. In a number 
 of instances the author has found involvement of the p;irty wall below 
 the arNtenoids posteriorly in cases free from ;n\tenoid lixation and 
 seemingly intrinsic. In (jther cases, e.xtrinsic by (origin or extension, he 
 has advised against laryngectomy because of glandular nodes observable
 
 4;i8 
 
 ENDOSCOPY IN MALIGNANT DISEASE OF THE LARYNX. 
 
 esophagoscopically in the esophagus, though covered with apparently 
 normal mucosa. In one such illustrative case a series of nodes were 
 seen at different locations from the left pyriform sinus to the level of 
 the upper thoracic aperture, indicating unremovable involvement. The 
 patient dying shiirtly afterward, enabled autoptical confirmation bv Dr. 
 Andrews (Fig. oS!) i. 
 
 Malignant disease of the epifflottis may be. in very rare instances, 
 an exception to contraindication of endoscopic e.xtirpation of malignancy. 
 
 Fig. 389. — Illustratin.tr the possiliilities of csophagoscopic aid in decision as to 
 operability of lanngeal malignancy. The author saw esophagoscopically the lymph 
 nodes, A, B, C, D, and others during life and advised against laryngectomy. 
 
 In those rare cases of malignancy strictly limited to the tip of the epiglot- 
 tis and of small extent, endoscopic removal is justifiable provided the 
 amputation of the epiglottis will give a sutlicientlv wide removal. The 
 author has had two cases of this kind, now well at the age of four years 
 and two years respectively. The method used was amputation as nearly 
 total as possible, of the epiglottis with the heavy snare. Fig. 41. The 
 disease was of very small extent and histologically was found by Dr.
 
 ENDOSCOl'V IX iMALIC.NANT DISKASli OF THE LARYNX. 439 
 
 W'illetts to be epitlieliomatous. Healing was prompt and uncomplicated. 
 Dela\an (Bib. 11" ) reports a cure of epiglottidean maHgnancy by indi- 
 rect removal. 
 
 Radium for mal'ujnmit disease of the larynx. As yet radium has 
 not given results that would warrant its use in any operable case in the 
 larynx or elsewhere. In inoperable cases excellent palliative results war- 
 rant its use. The dosage and screening required are about the same as 
 will he given later for esophageal malignancy. The container with heavy 
 dosage may be held in place under ocular observation as was done by 
 Dr. Ellen J. Patterson for thirty minutes at each sitting using cocaine 
 anesthesia. Or a tracheotomy may be done, the capsule placed above 
 the tracheotomic cannula t(j which it is tied with braided silk as is done 
 with the author's laryngostomy apparatus (q. v.). The following is a 
 report of Dr. Ellen J. Patterson's case: 
 
 indirect laryngoscopy showed the condition sketched at .A, Fig. :i:io. 
 The left side was apparently uninvolved, but on the right the entire 
 aryepiglottic fold including the arytenoid eminence was infiltrated, thick- 
 ened and covered with nodules of a dark reddish color. There was only 
 slight movement of the right arytenoid. The growth seemed to involve 
 the external portion of the \entricular band and there was a slight in- 
 filtration at the Iiase of the epiglottis on the right side. A large mass of 
 glands was palpable in the neck low down along the sternomastoid muscle. 
 A large specimen was removed and submitted to Dr. Ernest W. W'illetts, 
 Professor ( )scar Klotz, Dr. W. Proescher of Pittsburgh, and Dr. K\ans 
 of Chic:igo, all of whom re|iorted the growth to be sarcoma. The jia- 
 tient was not seen .'igain until one month later. Upon indirect examina- 
 tion the growth had almost doubled in size overhanging the glottis as 
 shown at I!, Fig. oini. There was now not the slightest motion to the 
 right arytenoid and the left seemed to be slightly impaired. There was 
 a very slight put'tiness about the base of the left arytenoid eminence. The 
 disease was clearly inoperable because of the very large mass of infil- 
 trated glands in the neck, the nodes seen esophagoscopically, and the 
 crossing of the process i)ast the posterior commissure. At the request 
 of the patient radium treatment was instituted by Dr. Patterson under 
 the advice of Dr. W. Proescher as to dosage and duration. Radium 
 bromide equivalent to l'> mgm. of radium element was applied daily for 
 thirt\' minutes, the well screened capsule being placed in contact with the 
 longest diameter of the growth. In addition, the patient was given a 
 capsule containing .V) mgm. of radium element which was bandaged over 
 the infiltrated mass of glands in the neck for ten hours daily. After one 
 month's treatment with the radium the condition, which had been as 
 shown at H. h'ig. oiin, liad entirely disappeared, leaving both aryepiglottic
 
 4-40 
 
 HNDOSCOP-i- IN MALIGNANT DISKASK OF THE LARYNX. 
 
 folds and arytenoids almost symmetrical as shown at C. Tiiere was 
 quite an imjiroved motility of the right arytenoid, though it was not able 
 to make more than half a normal excursion. The patient was not seen 
 again until two months later when it was found that there was an ede- 
 matous-looking slight enlargement of the right aryepiglottic fold, though 
 it was not nodular and not of the dark color of the primary condition. 
 Down on the posterior surface of the right aryepiglottic fold there could 
 be seen the upper edge of an ulcer which extended downward into the 
 right pyriform sinus, involving its anterior wall, as shown at D. When 
 the lar\nx was drawn forward with the direct laryngoscope, the ulcer 
 was seen to extend nearly 2 cm. down into the hypopharynx. Dr. Pat- 
 terson removed a specimen from the edge of this ulcer. Dr. Ernest W. 
 AVilletts reported it to be an undoubted epithelioma with typical epi- 
 
 FlG. 390. — I lliiMraliiiy a c.ix.- ui l.iiviiytal sarniiiia in a man ol 37 \ears. The 
 growth (B) disappeared under radium treatment as shown at C. Epithelioma ap- 
 peared later as shown at D. Heavier radium dosage caused disappearance of the 
 epithelioma. The growth, prior to treatment, had increased from the size shown 
 in A to the size shown in B. Death occurred about a year hiter of recurrence and 
 metastases (Case of Dr. Ellen J. Patterson.) 
 
 theliomatous cell pictures. Drs. I'roescher and Klotz concurred unquali- 
 fiedly. Under the advice of Dr. Proescher radium bromide equivalent 
 to 201) mgm. of radium element was applied for a half hour on alternate 
 days for five applications. This caused the disappearance of the growth. 
 One year later the patient died of recurrence and metastases. 
 
 Remarks. Lues was excluded by a very thorough therapeutic test 
 by Dr. Lawrence Litchfield and Dr. L. C. Ilixler. The eminent pathol- 
 ogists mentioned all agreed that there was absolutely no histologic evi- 
 dence of cancer in the first specimen taken, wliich was a very large one. 
 and hence fairly representative of the neoplastic process then present. 
 It seems justifiable to suppose that the radium caused the disappearance 
 of the primarv condition. The change from a connective tissue type of 
 neojilasm to an epithelial ty])e seems to the author very rare, as he had 
 ne\er before seen such a case. Mr. Walter G. Howarth, who, when
 
 ENDOSCOPY IN MALIGNANT DISKASK Ol" Till-: LARYNX. 44] 
 
 honoring the author's clinic with a visit, saw the patient at the stage 
 shown at D, mentioned a case of his own in which there was a change 
 from an epithelial tissue type to a connective tissue type. A papilloma 
 was removed from the uvula of a boy. This was followed six months 
 later by a growth in the \elum bulging both anteriorly and posteriorly. 
 Mr. Howarth removed the entire velum with the tonsil, followed by per- 
 fect healing. This growth was found to be a fibroma. Four months 
 later a pedunculated mass developed in the scar and was removed by ex- 
 ternal operation along with involved glands. This growth was found to 
 be a spindle-celled sarcoma. This operation was followed by hopeless 
 recurrence from which the last specimen examined showed a small round- 
 celled sarcoma. All of the specimens were examined by Mr. Shatluck 
 and all of the operations were done by Mr. Howarth. Such cases are 
 exceptions to the law that tissue never changes type. The efficiency of 
 radium in prolonging life in Dr. Patterson's case is undoubted in view 
 of the rapid growth in one month's time prior to treatment as shown by 
 comparing A and 1!, l-'ig. ;'>!»0. That an ultimate cure did not result is 
 disappointing, but the palliative results were well worth while. 
 
 Diathermy. Mr. Douglas Harner reports such excellent results from 
 dialhennv in the treatment of inoperable laryngeal and faucial malig- 
 nancy that its use alone or cojointly with radium promises excellent 
 palliative, possibl\- cmatixe results. (See Journal of Larynyoloijy, Nliiii- 
 oloyy and Otoloqy, October, IIU 4.)
 
 CHAPTER XXVI. 
 
 Bronchoscopy in Malignant Growths of the Trachea. 
 
 The author has seen but one case of maUgnant tumor originating in 
 the interior of the thoracic trachea, at a stage when such origin could be 
 verified. But such cases occurring in the subglottic region of the larynx 
 have been observed by all laryngologists, including the author, and post 
 mortem findings would indicate that endobronchial or endotracheal origin 
 does occur. A case of cancer, probably arising from an endotracheal 
 mucous gland in the subglottic trachea, is reported by Sir Robert Woods. 
 The bronchoscope offers a means for the early diagnosis of malignant 
 tumors of the thorax. As these tumors occur most fre(|uently at the 
 hilus, it is seldom that even an early diagnosis renders surgical extirpa- 
 tion ])ossible, and yet with the rapidK advancing development of thoracic 
 surgery it behooves us. as endoscopists, to develop the early diagnosis of 
 malignancy to the utmost in order to be of assistance to the general sur- 
 geon, .^s is well known, neither the X-ray nor [ihysical signs give any 
 evidence of inediastinal malignancy at a very early stage. Posticus 
 paralysis, it is true, is cpiite an early evidence, but in most cases it is 
 simply an indication for further investigation in order to determine 
 whether or not the paralysis is due to intrathoracic conditions. Tlie 
 most common form of malignancy in the trachea is a secondary process 
 from a peritracheal growth. As enumerated under the head of malig- 
 nant disease of the esophagus, the author has seen quite a number of 
 cases where the trachea, or, more often, the left bronchus was invaded 
 by a tumor which also invaded the esophagus. It is not often possible 
 to determine the point of origin of the growth. It may Ije in the trachea, 
 in the esophagus or, more probably, in the mediastinum. The endo- 
 tracheal appearances are quite similar to malignant disease elsewhere. 
 In the later stages, which the process has practically always reached by 
 the time it comes to the endoscopist, endotracheal and endobronchial 
 malignancy are characterized by a bleeding mass of fungatiiig tissue 
 bathed in ])us and secretion, usually foul. The diagnosis of a malignant 
 process wliicii has already involved the lumen of the trachea is to be made, 
 not so much by the endoscopic appearances as bv the removal of a speci- 
 men of tissue. Xo danger whatever attaches to this if carefullv done and 
 if aneurysm be excluded. As elsewhere stated, an aneurysm large enough 
 to invade the tracheal lumen can easily be diagnosticated by radiography, 
 fluoroscopy and by the internist. Sarcoma and carcinoma of the thyroid 
 gland when perforating into the trachea, as pointed out by Sir Felix 
 Semon ( Bib. 471 ) usually become pedunculated.
 
 BROXCIIOSCOPY IX MAI.ICiNANT GROWTHS OF THE TRACHEA. 443 
 
 I'eritracheal or periljronchial malignancy mav cause a compressive 
 stenosis co\ored with normal mucosa. Endoscopically the wall is seen 
 to bulge in from one side at any part of the lumen causing a crescentic 
 picture, or compression of oi)iiosite walls may cause a "'scabbard" or 
 pear-shaped lumen. L'sually the compression will be found hard and 
 firm and the involved bronchus less easily moved laterally than normal. 
 Deviation of the trachea may be marked in peritracheal malignancy and is 
 to he distinguished from anomalous deviations by the compressive hard- 
 ness and fi.xation of the former. Compression by normal or malignant 
 thyroids, especially retrotracheal malignant goitre renders bronchoscopic 
 exploration advisable as a preliminarv to operation as mentioned imder 
 "Anesthesia." The reader is referred to the beautiful and instructive 
 ".\tlas der Rronchoskopie'' by Dr. AT. Mann (Bib. .Tlil) for pathological 
 studies of cases of mediastinal malignant disease with endotracheobron- 
 chial manifestations discovered bronchoscopically : also to the excellent 
 article of Mosher (Rib. 4o:!), Theisen (Bib. .")4Sj and of Ingersol (Bib. 
 319). 
 
 Treatment. L'p to the jircsent time but one case of sticcessful ex- 
 tirpation of malignancy has come to the writer's knowledge. This was a 
 case of Kahler, in which a tumor of the right bronchus was removed 
 bronchoscopically, its insertion being afterward cauterized with the 
 galvano-cautery. The tumor was found to be a papillary cylinder-celled 
 carcinoma. At the time of the report the patient had remained free 
 from recurrence at the end of two and one-half years. Ephraim reports 
 the removal of heinorrhagic and obstructive fungations of malignancy 
 with tile subsequent application of the galvano-cautery with great relief 
 of pain ;uid the arrest of hemorrhage and the lessening of dyspnea. Un- 
 til a tlH-ra|ieutic cure shall be disco\ere<l most of the cases will be sub- 
 jects for a ])alliative tracheotomy and radium therapy. The methods, 
 screening and dosage are proljably about the same as those given for 
 eso])hageal malignancy. In doing a tracheotomy it is necessary not only 
 to oi)en the trachea to put in a cannula, but to make sure that that can- 
 nula gets down below the diseased ])rocess and ])ipes the air down to one 
 or both bronchi wiiich arc still functionating. In ijuitc a number of the 
 author's cases there has been a mere fistulous tract kept open by the 
 long tracheal cannula long after the tracheal wall has been obliterated 
 by the cancerous ])rocess throughout a greater or less jiortion of its ex- 
 tent. The patient is able to get up secretions better through the long 
 tracheal cannula than he can through the diseased trachea even if he 
 could get air enough <lo\\n without the cannula, whicli is seldom the case, 
 so that tracheotomy with the long tube probably prolongs the patient's 
 life by lessening the absorption, as well as by preventing asphyxia.
 
 CHAPTER XXVII. 
 
 Malignant Disease of the Esophagus. 
 
 Canctroiis lesions of the esophagus are usually single. This is rare- 
 ly discoverable esophagoscopically, because it is rarely justifiable to push 
 an esophagoscope beyond the site of the first lesion. Nevertheless, as a 
 post mortem fact, it has been demonstrated by Seelig (Bib. 40!)) that 
 implantation metastases nia\ exist in the esophagus below the primary 
 lesion (Fig. 391). Malignant disease of the esophagus is rather more 
 frequent at the upper extremity, next in frequency is the lower extremity 
 near the cardia, the middle portion being least often involved. In all 
 cases of suspected cancer, it is necessary to exclude aneurysm by radiog- 
 raphy before making an examination. Then in proceeding with the 
 esophagoscopy it is necessary to exercise great care to pass the tube by 
 sight and not with a mandrin, because the growth may be higher situated 
 than is suspected. (Jf course this same rule applies to all esophagoscopy, 
 Init there has been quite a number of cases re])orted where the esoph- 
 agoscope had perforated the very much weakened wall of a malignancy 
 situated close to the cricopharyngeal narrowing. Therefore, it is neces- 
 sary to be doubly careful, especially as the infiltration may make the 
 passage of the esophagoscope more difficult than usual in this narrow 
 portion of the eso])hagus. Unfortunately, malignant disease of the esoph- 
 agus is but rarely seen early. There are two reasons for this. First, 
 the early stages of the disease produce no symptoms. Second, when 
 symptoms begin to appear they are so slight that usually neither patient 
 nor attending physician suspects serious disease, calling for immediate 
 esophagoscopy. With a wider recognition of the usefulness of the esoph- 
 agoscope for early diagnosis, there will be a change in this respect. It 
 should be an absolute rule that no transthoracic operation for malig- 
 nant disease of the esophagus should be attempted until after a specimen 
 has been removed and the diagnosis confirmed. For the removal of this 
 specimen, of course, the esophagoscopic method is the onlv one. The
 
 MAl.IC.NANT niSKASIv OK TIIK KSOPII AGUS. 445 
 
 specimen should be ample, and should, if possible, include a little of the 
 adjacent normal, though greater care is needed here than elsewhere as 
 to the amount of normal that may be taken. A little of the mucosa is 
 suflicient. The only contraindication to the taking of a specimen is such 
 a profoundly anemic condition that oozing which mav follow may turn 
 the balance against llic paliciu. This anemic condition is usually only 
 found in diose cases that have been permitted to become moribund from 
 hunger and thirst from too long delayed gastrostomy. Tn such cases the 
 gastrostomy sho'.'.ld be done at once and the [latient fed until the specimen 
 may be taken with safety. L'nfortunately. such patients, especially if 
 there have been a few days of water hunger, make exceedingly bad sur- 
 gical subjects, so that the minor ojieration of gastrostomy assumes a 
 
 Fk;. 391. — Implantation nictaslasi.-s in the csopluif^us. DiaRrammatic repre- 
 sentation of a coiled up longitudinal section. The primary lesion at upper end of 
 esophagus is seen at 2; at the lower end :ii 1. Tlic lesions at 4 and 5 arc metastatic, 
 (Sec article hv M. C. Seelig, Bih. 469.) 
 
 high mortality. Cases of suspected cancer, like c\cry other esophageal 
 condition, should be examined locally with an cso])hagosco])e before any 
 attempt is made to |)ass any instrument blin<lly. The author cannot 
 agree witli those who, for an\- ptirposc whatsoe\er prefer to pass a 
 bougie lirst. There lia\e been too many acciilcnts from this ]irocedure, 
 and the author can see no advantage whatever in it, for there is nothing 
 to l)e learned by sounding that cannot be learned esojjhagoscopicallw and 
 so far as the patieiU is ccinccrned, it is no nv>[\- .innoyancc to have an 
 esophagoscopc p.'isscd than to have a sound passed. As for the deter- 
 mining by such a method the length of the tube to be used, which is the 
 last remaining excuse given, it is (|uite needless. The .luthor's custom is 
 to examine the upper region of the esopiiagus lirst with the esophageal
 
 44(5 MALIGNANT DISEASE OF THE ESOPHAGUS. 
 
 speculum and then to pass the 53 cm. esophagoscope. which is the only 
 one needed for adults. Sarcoma is much less frequent than carcinoma 
 but does occasionally occur. It is exceedingly seldom that there is any 
 dilatation above a cancerous stenosis, possibly because the stenosis is 
 seldom sufficiently obstructive until late in the disease. Occasionally, 
 however, quite a considerable dilatation has been observed by the author 
 which leads to the suspicion that there was some spasmodic condition 
 prior to the development of cancer, and possibly the cancerous process 
 was implanted upon the chronic inflammation. 
 
 Esophagoscopic appearances and diagnosis of malignant disease of 
 the esophagus. The esophagoscopic appearances of cancer vary greatly, 
 according to the stage in which the disease is seen, and also according to 
 whether the esophagus or neighboring viscera are jirimarily invaded. 
 The following forms of lesion are those usually seen : 
 
 1. Submucosal infiltration covered by perfectly normal membrane, 
 usually associated with more or less bulging of the esophageal wall, and 
 usually associated with hardness and infiltration. 
 
 2. Leucoplakia. 
 
 3. Ulceration projecting l)ut little above the surface at the edges. 
 
 4. Rounded nodular masses grouped in mulberry-like form, cither 
 dark or light red in color. 
 
 .5. Polypoid masses. 
 
 6. Cauliflower fungations. 
 
 In considering the esophagoscopic appearances of cancer, it is neces- 
 sary to remember that after ulceration has set in the cancerous process 
 may have engrafted upon it, and upon its neighborhood, the results of 
 inflammation due to the mixed infections. Cancer invading the wall 
 from without may for a long time be covered with perfectly normal 
 mucous membrane. The significant signs at this early stage are : 
 
 1. Absence of one or more of the normal radial creases between 
 the folds. 
 
 2. Asymmetry of the ins]iiratory enlargement of lumen. 
 
 3. Sensation of hardness of the wall on pal])ation with the tube. 
 
 4. The involved wall will not readily be made to wrinkle when 
 pushed upon with the tube mnuth. 
 
 In determining deformit\- of the outline of the esophageal lumen, 
 it is necessary to be careful that the head of the patient is not rotated: 
 because rotation may cause distortion of the esophagus as demonstrated 
 graphically in the radiogra]>h. Fig. 392. In the later stages, when the 
 submucosal growth begins to break through, the mucous membrane be- 
 comes nodular, and then is usually darker in color with apparent great 
 increase of vascularity. In the fungating forms of cancer, the funga-
 
 MALIGNANT DISKASIC OK THE KSOPHAGUS. 
 
 447 
 
 tions may lake a polyimid sliai'L-, tin- individual jjolypi being covered witii 
 epithelium and the general color being quite similar to normal esophageal 
 mucosa or to nasal edematous (lolypi, or they may be (|uite red. This 
 latter form is rather rare. Much more common are the fungations which 
 look like exuberant granulations in an unhealthy woiuul. We also oc- 
 casionally see white grass-like [irojections such as are seen at times in the 
 
 Fig. 3QJ. — Radiograiih of a coin in the esophagus, showing the diagonal res- 
 piratory esophageal movement with rotated head, and illustrating the necessity 
 of the exact median non-rotated position nf tlie head if any diagnostic importance 
 is to be attached to asymmetrical respiratory esophageal movement in escphagos- 
 copy for suspected periesophageal or submucosal esophageal lesions. Incidentally 
 this illustrates, also, one of the disadvantages of the lateral position for esoph- 
 agoscopy for disease. Radiograph by Dr. George J. Boyd. 
 
 larynx. The ulcerated fcirms of esophageal malignancy seldom resemble 
 ulceration seen in the nuicosa hit;her up. I'art of this seeming dissimi- 
 larity is due to the |iosilion in which the ulcer lies with reference to the 
 jioint of view. I'lceratinn in the csojihagus is seen more or less on edge 
 throtigh the esoiihagoscopc, and because of the basal infiltration, it is 
 seldom feasible to turn the ulcer sidewise, as could be dotie by lateral
 
 448 MALIGNANT DISEASE OF THE ESOPHAGUS. 
 
 pressure on the esophageal wall above the ulcer if it were not for the 
 infiltration beneath, [f a very large esophagoscope is used, there is more 
 or less turning of the ulcer and then the crater can be seen, and also the 
 distal edges. The edges, in some instances, are under cut. though usually 
 not. In many instances there are smaller budding granulations along 
 the edge of the ulceration. In some instances, the ulcerations are cov- 
 ered with whitish projections, looking somewhat like papillomata, but 
 the individual projections are more pointed. The center may be some- 
 what lower than the periphery, and in many instances is covered with a 
 layer of exudate, whitish or yellowish in color, the exact color depend- 
 ing, of course, on the degree of illumination. There is almost invariably 
 more or less oozing of blood, even before an\- instrument or gauze sponge 
 has come in contact with the ulcerated surface. In some instances, the 
 border may be very irregular with a mouse-gnawed ajipearance to the 
 edges. In one of the author's cases the ulcerated area seemed flat, almost 
 depressed, while on top of it was lying a mass of slough and exudate, 
 apparently about ready to detach. All of the foregoing types may occur 
 in the same case, either at different stages or all may co-exist in one 
 lesion. It is quite common to see at least two forms combined in the 
 same lesion. Two things are characteristic of all later forms of lesions. 
 All are bleeding when first seen, or bleed very readily when wiped with 
 the sponges. They all convey the idea of rigiditv or fixation of the in- 
 volved area, which is in marked contrast to the normally thin, easily 
 movable, supple esophageal wall. There is every reason to believe that 
 the very early stage of cancer occurs as leucoplakia in at least a few 
 cases of esophageal cancer. There have, so far, been only a few cases 
 observed, but opportunity for very early esophagoscopies in cancer are 
 so rare that there is no means of determining how frequent such an on- 
 set may Ije. The author has seen three cases of which the following is 
 one: 
 
 •Male, aged .")il, was admitted to the Presbyterian Hospital for diffi- 
 culty in swallowing of about two weeks' duration. The onset had been 
 c|iiite sudden, at which time he had been unable to swallow anything but 
 liquids. On passing the esophagoscope. we encountered, just above the 
 hiatal level, a white patch about 1 cm. in diameter that looked precisely 
 as if the mucosa had been burned with silver nitrate. The appearance 
 was so much like that of the mucous plaque, and the onset of the symp- 
 toms had been so recent, that we ordered the patient at once put upon 
 antiluetic treatment, notwithstanding a negative history and normal 
 glands. At the end of four weeks there was no amelioration of the 
 symptoms, and on passing the esophagoscope I found conditions jirecisely 
 as before. .\t neither of these two examinations could I determine anv
 
 MALIGNANT DISEASE OF THE ESOPHAGUS. 449 
 
 Stenosis of the esophagus. The 10 mm. esophagoscope passed readily 
 into ihe stomach without obstruction, so that it was quite evident that 
 the symptoms from wliich the patient suffered must have been due to 
 spasm, though we were somewhat surprised that the passage of the esoph- 
 agoscope the first time had not reHeved the symptoms, temporarily at 
 least, as is usual in case of spasm. This patient went west and died of 
 "cancer of the stomach." A gastrostomy was done for feeding about 
 two months before his death. Xo other data were obtainable. 
 
 Sarcoma of the csophaijiis probably resembles in a general way the 
 appearances seen in cancer. The author has seen but one case of esopli- 
 ageal sarcoma. There was a round nodular mass on the posterior 
 esophageal wall. (|uile dark in cnlor and covered with vessels running in 
 all directions. At ibc lower border was an ulceration, with elevated edges 
 and depressed center ( b'ig. !l, J'late III). No fetor was noticeable. 
 
 Differential diagnosis. The differential diagnosis by esophagoscopic 
 appearances alone, while not absolutely positive, yet will be rarely in 
 error with any one who is accustomed to seeing malignancy of mucosal 
 surfaces. In cicatricial stenosis, we have a thin, white, web-like band, 
 'or thin-edged annular stricture with a dilatation above it. In spasmodic 
 conditions, we have the vertical fold running down into a funnel-shaped 
 l)oint ending in a concentric lumen of minute extent; the mucosa is 
 either normal or pasty and macerated, or in a state of chronic esophagitis. 
 This condition is usually more or less diffused, and there is an absence 
 of that rigidity and infiltration that is seen in malignancy. In the ul- 
 cerated type of cancer, it may be exceedingly difficult to exclude lues 
 without a therapeutic test. The differential diagnosis between compres- 
 sion stenosis and cancer of the submucous type, is based upon the rigidity 
 and fixedness existing in the esophageal wall, and the fact that this wall 
 cannot be wrinkled up in cancer while it is freely movable in c()mi)res- 
 sion. In com])ression a'so we have oljliteration of the lumen to a long 
 nariiiw slit. In llie leuc<]iilakia t\pe. mucous patches of lues can be ex- 
 cluded only by the therapeutic test. After all, we must rely mainly upon 
 the histologic examination of an esophagoscopically removed specimen 
 wliich should, in all cases, be as amjile as possible and should include a 
 l>()rtion of the adjoming normal. 
 
 'I'rcatmoit of mdliijiiant disease of the eso[>hu(/HS. Cancer of the 
 esophagus has, at the jiresent day. I'lo |ier cent mortality, but there is 
 good reason to believe that the surgeon will show a certain percentage of 
 cures as soon as ]ihysici;uis will i>rom]itl\- refer to the esophagoscojiist all 
 patients showing the slightest abnurmality referable U< the esophagus. 
 Thus only can we ho[)e to discover and treat the early cancerous and 
 precancerous conditions of leucoplakia, erosion, maceration, chronic
 
 450 MALIGNANT DISEASE OF THE ESOPHAGUS. 
 
 esophagitis, etc. That the physician may do this without hesitation, it be- 
 hooves the esophagoscopist to so perfect his technic and develop his 
 skill that a patient may be esophagoscoped without distress and without 
 anesthesia, or at most with local anesthesia limited to the pharynx. The 
 work of Henry Janeway, Willy Mayer, Charles A. Elsberg and others 
 has convinced the author that resection of the thoracic esophagus is a 
 practicable procedure and will be frequently resorted to as soon as early 
 esophagoscopies shall make the necessary early diagnosis. The passage 
 of an esophagoscope for diagnosis often gives great relief of dysphagia, 
 and this has lead to advocacy of the old method of bouginage. It is, 
 however, of questionable advisability even for palliation. 
 
 Gastrostomy is always indicated sooner or later, and it should al- 
 ways be done before the patient's nutrition fails. Like tracheotomy, we 
 all preach its early performance, but usually do it late. The surgeons 
 who advise against gastrostomy forget that their experience is based on 
 cases operated too late. Granting that the patient is a victim of a fatal 
 disease, there is no reason why he should die in the agonies of thirst and 
 hunger. Death from exhaustion is fairly comfortable, but death from 
 hunger and, especially thirst, is agonizing, and the agony is prolonged- 
 by the tantalizingly small amount of fluid that passes the stenosis. If 
 the gastrostomy be done early, there is no unquenchable thirst, no un- 
 satisfied hunger, and most beneficent of all, is the almost invariable im- 
 provement in the ability to swallow through the esophagus that follows 
 the esophageal rest after gastrostomy. 
 
 Intubation of the esophagus. In the palliative treatment of inoper- 
 able esophageal cancerous stenosis, gastrostomy may be postponed by 
 esophageal intubation, in many instances, until very nearly the termina- 
 tion of the case, though by this it is not meant to advise that gastrostomy 
 should be postponed one day after it is clear that nutrition is going to 
 suffer. It is, of course, much more satisfactory to tiie patient to swallow 
 his food even though it be liquid, than to have it poured in through the 
 abdominal wall. Esophageal intubation has been very satisfactory in 
 the atithor"s hands. All forms of clear liquids will go through esoph- 
 ageal intubation tubes of 4 mm. internal diameter, and raw or very 
 slightly cooked eggs can, with care, be swallf)weil witli much satisfac- 
 tion by the patient whose esophagus is thus intubated. In fact, any finely 
 masticated food will go through, though occasionally imperfectlv mas- 
 ticated particles may lodge in the smallest tubes. The author has had 
 these tubes worn for quite a number of months without exciting ulcera- 
 tion, though, of course, cancerous ulceration was already present in some 
 instances. The tubes should be removed every week or two for clean- 
 ing. It is essential to have a duplicate tube fi)r immediate replacement
 
 MAi.ii'.XAXT riisTA^i' CI' iin I scirii Ar.r-- 
 
 451 
 
 Fif!- 393- — CliartiTs Symonds esoplKiKial iiuuli.ili 
 esophageal caiucr ( Xmhnr's case). 
 
 11 uiliis in >iiu in a ca^c ol
 
 452 
 
 MALIGNANT DISEASE OF THE ESOPHAGUS. 
 
 else the esophageal channel will quickly close so that a smaller tube will 
 be needed. Eventually a smaller and a smaller tube is needed anyway, 
 until none can be introduced. The Charters Symonds tube was intended 
 for introduction with a whalebone stylet, without endoscopic aid. In- 
 troduction is greatly facillitated. however, by drawing forward the 
 larynx with the laryngoscope. The thread may be dispensed with and 
 withdrawal accomplished when necessary with the esophagoscope and 
 forceps. In removal of the esophageal intubation tube by the thread 
 without the esophagosco])e the funnel-shaped tube will always catch on 
 the cricoid cartilage and serious traumatism may be inflicted if the oper- 
 ator continues to pull. Drawing the larynx anteriorly with the laryngo- 
 scope or esophageal speculum, just as if we were exposing the crico- 
 pharyngeal constriction, will readily release the tube so that it can be 
 
 l-iG. 394. — Esophageal intiibntion tube of Guisez. 
 
 withdrawn. This is a very important procedure to remember in the 
 withdrawal of any instrument from the esophagus. Serious and even 
 fatal trauma has been inflicted more often in the withdrawal of such 
 instruments as the Graefe basket than in their insertion. The Charters 
 Symonds tube hi situ is shown in Fig. oiKl. C.uisez has devised soft rub- 
 ber intubation tubes that seem excellent (Fig. '-VJi). 
 
 Radium in the treatment of esophageal maliiinancy. The author 
 has not yet seen any results with radium that would justify his urging 
 its use in any case that is amenable to operative treatment. He has seen 
 marked eft'ects in inoperable esophageal malignancy, but so far no abso- 
 lute cures. In none of the cases has sufficient time elapsed to pass final 
 judgment upon the value of radium therapy in neoplasms. The author 
 would prefer to wait for three or four years before giving complete and
 
 MALIGNANT DISKASK OI" THE KSOI'II AGUS. 453 
 
 tabulated data of his results. In order, however, that other workers in 
 this field may have the use of such technic as the author has developed, 
 he deems it best to i)ublish this technic in the hope that it may be helpful 
 to other workers. The chemistry, physics, and, to a still greater extent, 
 the physiologic and therapeutic activities of radium are in such an em- 
 brj'onic state of development at the time this book goes to press, that 
 it is quite impossible, even if the author were capable, to give any final 
 conclusion. For all work with which endoscopj' has to deal, the con- 
 sensus of opinion is that the penetrating or gamma rays are the most 
 effective. To avoid the irritating effect and burns that the softer beta 
 rays would produce, it is necessary to absorb these rays with suitable 
 thickness of metal screen, usually silver or lead of from 0..5 to 3 mm. 
 in thickness. \\'herever gamma rays emerge from a metal there are set 
 up secondary radiations, which are soft like the very easily absorbed 
 beta rays. These secondarj' rays are very irritating and soon produce 
 serious superficial burns. To avoid these deleterious efl:'ects, it is neces- 
 sary further to screen the metal outside with the equivalent of 1 or 3 
 mm. of rubber, cloth or paper. When so screened with lead and rub- 
 ber, a quantity of radium equal to IDO mgm. of element can be applied for 
 hours without jiroducing a burn, whereas, 10 mgm. of radium with no 
 more [)rotcction than the walls of a glass tube, in contact with the tis- 
 sues for ten minutes, will lead to serious burns. The shorter the period 
 of application of radium, the larger the quantity that must be used, since 
 an inadequate d(jse of the radiation merely stimulates a new growth to 
 more rapid proliferation. As the power of the ray diminishes as the 
 square of the distance from the radium, it necessarily follows that the 
 tissues to be acted upon must be as close as possible, and wherever it can 
 be so arranged, the neoplastic tissues should be in contact with the 
 radium container, while normal tissues should be at as great a distance as 
 possible. When we have to deal with a large cancer surrounding the 
 esophagus, as shown .schematically in Fig. 3!t."), there is no doubt, as deter- 
 mined by biopsy by Dr. Andrews in consultation with the author, that 
 the periphery of the growth, as shown at P, is stimulated by the atten- 
 uated ray that is able to reach it through the thickness of the tissue M. 
 The tissues, H, in contact with the tube, R, should be (|uickly melted 
 away by large dosage in order to reach the peri|)heral cells shown at P, 
 before the latter have had too long a time to develi)]). In the endoscopic 
 application of radium, to obtain results it is necessary to use large dosage 
 for a less time rather than a less dosage for a longer time, because of the 
 discomfort of any esophageal application. I'.y either the larger or the 
 smaller dosage i)lan, it is necessary that such a degree of radio-activity 
 be developed that it is unwise to have the container in contact with
 
 454 
 
 MALIGNANT niSICASIC dl" 'I'lIF. USOPIIAGUS. 
 
 healthy tissue. In esophageal work the only way to be sure that the 
 container is in contact with neoplastic tissue, and no other is to do the 
 work esophagoscopically and to see that the container is placed precisely. 
 The only way to make sure that the container remains where placed, is to 
 see that it is in place by frequent inspection. ^\'ith all forms of blind 
 introduction there is an uncertainty that renders safety of radium treat- 
 ment questionable. It has been suggested that a watch on the position of 
 the capsule be kept by the fluoroscopic screen with roentgen ravs. The 
 esophagoscope having been removed, the replacement of the capsule, if 
 found displaced, is to he made bv a rigid wire carrier attached to the 
 
 F'G. 395.^Schematic representalion of a radium capsule in the center of an 
 annular esophageal cancer. 
 
 capsule. This is objectionable because of its inaccuracy, the exact posi- 
 tion of the stricture not being \isible fluoroscopically without bismuth : 
 and especially because it prevents the use of the flexible joint so necessary 
 for accurate applications to deviated luniina. 
 
 The author's method is as follows : The radium salt used is con- 
 tained in a very small glass capsule, and this capsule is contained in a 
 metal capsule •'> mm. in diameter, the wall of the capsule being 0.3 mm. in 
 thickness. Outside it is covered with a coating of hard rubber vulcan- 
 ized on (M, Fig. 397). This silver capsule has a solid ring or eye in 
 one end. A long extra drainage tube (B, Fig. 39ti), which was used by 
 the author in his early work for aspirating secretions from the bronchi
 
 MAMCNAXT DISK VSE 01" TIIK KSOPIIAGUS. 
 
 455 
 
 before he perfected his "sponge-pumping" metiiod, was found to make 
 the best possible carrier of the utmost simplicity. A small wire is 
 passed through the aspirating tube and brought out at the distal end. .\ 
 loop of heavy braided silk (not twisted silk) is attached to the wire, and 
 the silk is thus drawn through the tube. To the silk at the distal end, 
 the capsule is attached by means of a loop (P), formed with a bow knot, 
 as shown in Fig. .'590. Xow by drawing the silk taut, and making it fast 
 around the shoulder of the proximal end of the drainage tube, the cap- 
 sule is brought firmly into the end of the drainage tube, but not so firmly 
 but that lateral inovement is pos^^ible. This makes a stifif joint at the 
 
 Fig. 396. — Author's method of applying radium endoscopically. 
 
 point where the eye of the capsule is drawn into the end of the drain 
 age tube, motion being i)ermitte(l as shown by the dotted line. 
 For the esophagus a drainage tube of lii) cm. is used, and for the 
 larynx, a .'id cm. length is sufficient, though one of 40 cm. would be 
 needed f(jr the bronchi. Any one who does not have the drainage tube 
 can get the proper length of brass tubing of .i mm. external diameter 
 from any instrimient maker. The piu-pose of the movement permitted by 
 the joint, is to allow the capsule to be placed flatwise when the axis of 
 application does not correspond witli the axis of the endoscopic tube. 
 Thus in treating the laryngeal case before mentioned, Dr. Patter- 
 son made the application by placing the capsule along the entire length
 
 456 MALIGNANT DISEASE OF THE ESOPHAGI'S. 
 
 of the aryepiglottic fold, which would have been impossible had the con- 
 tainer been rigidly held in any form of carrier. In the use of forceps, 
 there is always the possibility of the capsule getting lost trom the grasp 
 of the forceps during the manipulation, and such an accident might be 
 exceedingly serious, because if not immediately recovered the prolonged 
 activity of the radium would certainly be fatal. For this reason also, the 
 braided silk used should be thoroughly tested. The first two or three ap- 
 plications in each case should be made with the esophagoscope in situ for 
 the entire time in order to see whether the container is moved by re- 
 gurgitant or other movements. For this purpose the esophagoscope 
 should be covered with hard rubber vulcanized on (Fig. 397) in order 
 to prevent irritant secondary rays. The esophagoscope and radium con- 
 tainer in situ in the living patient are shown in Figs. 398, 399, 4()0, 401 and 
 402. \\"hen satisfied that the radium capsule will stay where placed the 
 
 Fig. 397. — Esophagoscopes with hard rubber screens vulcanized on, to cut 
 down irritating secondary radiations. 
 
 silk may be untied from the proximal end of the drainage tube and the 
 esophagoscope and drainage tube may both be withdrawn leaving the 
 capsule in situ with only a string for later withdrawal (Fig. 400). 
 Anesthesia is not necessar}'. The best position of the patient for radium 
 applications to the esophagus with the esophagoscope in situ is the re- 
 cumbent, because the esophageal drainage, already defective, is occluded 
 by the radium container, the hypopharynx fills and the overflow into the 
 larynx excites constant cough and strangling, which makes a very trying 
 ordeal for the patient. In the recumlient position the secretions all flow 
 into the fauces and are aspirated through the tube. Fig. 24. attached to 
 the aspirator, Fig. 23. When the radium container is left in situ and the 
 esophagoscope is withdrawn the patient may lie face sidewise on the 
 table to permit secretions to drain away. 
 
 Dosage is dependent on duration of the applications. The equivalent 
 of !I00 milligrams of radium element well screened may be left in situ
 
 MALIGNANT DIS1■;.\^I■: Ol" TIIIC K.SOl'llAGUS. 
 
 457 
 
 Fic. 398 — Radium container in situ in a case of esophageal cancer. The ex- 
 cessive forward inchnation of the capsule is partly due to malignant distortion. 
 (The normal esophagus tends somewhat forward in this location). 
 
 Fir.. 399. — Radium capsule in place in a case of esophageal cancer. The esoph- 
 agoscopc, screened with hard ruhber, is kept in situ to watch the position of the 
 capsule until certain it will not shift.
 
 458 
 
 MALIGNANT DISEASE OF THE ESOPHAGUS. 
 
 for two or three hours, the applications being repeated on alternate days 
 for about ten applications. If excessive local reaction or general tox- 
 emia result the treatment should be interrupted for a few weeks. These 
 dosages are given with reservations. The future may determine them to 
 be too large or too small. Mr. ^Valter G. Howarth has been getting ex- 
 cellent results from the use of 100 mgm. kept in situ by means of a wire 
 
 Fig, 400. — Radium container in situ in a case of esophageal malignancy, 
 stout braided silk cord is attached to the eye but does not show. 
 
 brought out through the mouth, for a (leriod of eight hours and has re- 
 peated the application twice or three times at inter\als of a few days. 
 Local reaction. The first effect noted is not usually seen until after 
 a few applications. Then the perimalignant inflammatory zone is seen 
 to have disappeared. The lumen through the growth increases in size 
 and fungations diminish. If the dosage is excessive or if not well 
 screened, inflammation with sloughing, and with exfoliation of epithelium 
 from the normal mucosa mav be noted.
 
 MALKiNAN'l" IHSI'.ASI-: Ol' T H K i:SOI' 1 1 AGUS. 
 
 459 
 
 Fig. 401. — Radio.q^raph nf radium container in situ showing fogging of the 
 plate by tile n'.dium rax s, iu nine minutes exposure. 
 
 Flc. 402. — Peroral radium ai)plie;'tion to cancer of tlie car<lia.
 
 CHAPTER XXVIII. 
 
 Direct Laryngoscopy in Diseases of the Larynx. 
 
 For diagnostic purposes the greatest usefulness of the direct method 
 has been in the laryngeal diseases of children, a field which prior to the 
 development of direct laryngoscopy could not be studied in the living. 
 For treatment, especially surgical treatment, the direct method has placed 
 endolaryngeal surgery on a plane impossible of attainment by indirect 
 methods. 
 
 Endoscopic appearances of laryiujcal disease. The appearance of 
 the mucosa as to color, edema, ulceration, infiltration and neoplastic pro- 
 cesses is so fully studied in books on laryngology that extensive consid- 
 eration here is needless. Besides the difference in form due to the point 
 of view previously referred to, only one point need be mentioned, name- 
 ly, the wide variations in color due to engorged vascularit\- induced re- 
 flexly by the presence of the direct laryngoscope so close to the laryngeal 
 orifice. As elsewhere explained, this engorgement varies with the anes- 
 thetic used, and is usually greater when no anesthetic at all is used for 
 the examination. It is always wise, therefore, to get, in the first view, 
 an accurate estimate of color. If covered with a mask of secretion this 
 must be quickly and gently wiped away after the first inspection. 
 
 Subglottic edema. This has been previously referred to. liecause 
 of the easily elevated mucosa and the abundant submucosal cellular tis- 
 sue it is often the first indication of perichondritis. \Vhen the latter has 
 been cured, a chronic edema or hyperplasia should be cauterized as shown 
 in Fig. 87. 
 
 Perichondritis, abscess and their sequelae are easilv diagnosticated 
 and treated in children on well known principles. Stenosis following 
 these conditions is the subject of a separate chapter. 
 
 Tuberculosis. The author is in accord with Kahler. who states 
 that indiscriminate surgical treatment of the tuberculous larynx is a mis- 
 take and has led to discredit, whereas proper!}- planned surgical meas-
 
 DIRECT LARYNGOSCOPY IN DISEASES OF THE LARYNX. 4(jl 
 
 iircs in selected cases have yielded excellent results. As stated by Mr. 
 Uavis (Bib. 100) — "When the larynx is involved a vicious circle oc- 
 curs, in which the dysphagia, sleeplessness, and cough produced by the 
 painful lesion markedly increase the rapidity of the progression of the 
 lung condition. The judicious removal by surgical methods of painful 
 lesions undoubtedly relieves jiain, and vig(jrous methods with careful re- 
 search are needed to attack the much-dreaded laryngeal tuberculosi.s." 
 
 Extirpation of tuberculous laryngeal lesions. When small and iso- 
 lated, extirpation of the entire lesion may _\ield excellent results as in 
 the following case : 
 
 A girl of eighteen years, referred by Dr. !',. L. Calhoun for increas- 
 ing hoarseness of some months' duration. Indirect larj-ngoscopy showed 
 a small projection from the right cord (A, Fig. 403) which looked like 
 
 Fig. 40,3. — Case of extirpation of a small isolated laryngeal tiilifrcuknis nodule, 
 in a girl of eighteen years. .\ Growth on right cord thought to be of inllamma- 
 tory origin hut later proven tuberculous. B. One week after e.xtirpation the cord 
 on the operated side does not seem to be drawn tense in attempted phonation. 
 C. Two weeks after operation phonation is perfect. D. Larynx on inspiration 
 live years after operation. 
 
 a singer's node. As a rule the author does not favor the removal of 
 singer's nodules, but as this was one-sided and was clearly the cause of 
 the hoarseness, the author yielded to the patient's demand that the growth 
 he excised in order to restore the voice promptly to enable the patient 
 to finish her year's contract as a singing teacher. The growth was re- 
 moved by direct laryngoscopy with very hapi)y results as regards voice. 
 Dr. Ernest W. Willetts reported the growth to be undoubtedly tuber- 
 culous. This diagnosis was subsetiuently confirmed by physical exam- 
 ination and by the finding of bacilli in llie sjiutuni, which, of course, came 
 from the [lulmonary lesion. Rest in bed, oi)en air and a complete anti- 
 tuberculous regime under the skillful care of Dr. Calhoun entirely cured 
 the pulmonary condition, and now, five years later, the patient's larynx 
 is as shown at D in Fig. in:;, entirely and comi>letely well. This case 
 illustrates clearly what may be done by direct laryngoscopic excision of
 
 462 DIRECT LARYNGOSCOPY IN DISEASKS OF THE LARYNX. 
 
 tuberculous growths. Manifestl}', however, it is ouly adapted to isolated 
 foci and is not to be applied to the usual massive arytenoid infiltrations. 
 Diffuse infiltrations are not amenable to extirpation, but encroachments 
 on the glottis may be removed with great relief of dyspnea and secondary 
 benefits from improved oxidation. 
 
 Amputation of the cpic/lottis. Tuberculosis of the epiglottis may 
 prove one of the most disastrous lesions that a tuberculous patient can 
 develop, not so much from the toxemia of the lesion itself as from the 
 odynphagia which interferes very seriously with the patient's nourish- 
 ment ; and, unfortunately, nearly all the applications that can be made to 
 lessen the pain of swallowing interfere with the appetite so that food is 
 not relished, and even nausea and vomiting may be induced. If ampu- 
 tation of the epiglottis is necessary, it is very easily accomplished by the 
 method gi\en in Chapter \TI. 
 
 Gak'ono puncture for laryngeal tuberculosis. Of the endoscopic 
 surgical methods galvano-puncture will soon be entitled to first place 
 since the advantages of its endoscopic use have been demonstrated. Deep 
 puncture produces the best results in infiltrations without ulceration, but 
 it is necessary to avoid punctr.ring the arytenoid joint. Next to these, 
 fungating ulcerations are most amenable. The fungalions after a single 
 application will often disappear and the ulcer will cicatrize. For ulcera- 
 tion superficial cauterizations are preferable. In difi^used edematous in- 
 filtrations deep punctures are to be preferred. Llcerative tuberculosis 
 of the epiglottis and lesions involving the posterior surface of the ary- 
 tenoid and mouth of the esophagus yield readily to cauterant treatment. 
 Excessive reaction sometimes follows the application of the galvano- 
 cautery, though rarely. It is best to make only a slight application at 
 first to see how much reaction the particular individual will probably 
 manifest. Deep punctures at a white heat produce less reaction than 
 superficial punctures or those made at a dull red heat. Perichondritis 
 has followed in some instances, but as this is quite a usual complication in 
 tuberculosis of the larynx it cotild not be determined in any of the cases 
 reported in the literature that the [lerichondritis resulted directly from 
 the cautery. They woukl ])rohably have occurred anyway from the 
 mixed infections at work in ulcerated areas. The technic of galvano- 
 puncture is alluded to under the head of direct laryngoscopy. 
 
 CO\GENIT.\L L.VRYNGEAL STRinOR. 
 
 Stridorous breathing may be due to aii\- one of many dift'erent forms 
 of obstruction of the larynx and trachea. The text books mention tradi- 
 tional sounds, signs and symptoms by which it was thought distinctions 
 might be made as to the different locations affected. To reiterate these
 
 DIRECT I.ARVNCOSCOPV IN DISEASES Ol' Tin; LAin.W. 463 
 
 would be useless. A diagnosis based upon anything but looking and see- 
 ing is wrong as often as right. Many different conditions were supposed 
 to exist to account for the symptoms of stridor coming on at or shortly 
 after birth and continuing for a year or two. Many of these hypotheses 
 doubtless applied to conditions which really e.xist in some cases, but it 
 seems best to limit the name to those cases of exaggerated infantile type 
 of larynx, as described by D. R. Paterson, A. Brown Kelly, G. A. South- 
 erland and H. L<ambert Lack. Sir St. Clair Thompson's description (Bib. 
 539) is excellent. "The epiglottis is very long and tapering, and its 
 lateral margins are rolled backward so as to meet, and thus form a com- 
 plete cylinder above. The greatly reduced entrance to the larynx is 
 bounded by the aryepiglottic folds which are too closely opposed to admit 
 any but the slightest amount of air. The croaking noise is caused by the 
 free and unsupported part of the posterior laryngeal wall and neighb(jring 
 loose tissue on the summits of the arytenoids which is sucked forwards 
 and inwards during inspiration." This description coincides with three 
 cases seen by the author, one of which is illustrated at D, in Fig. 93. 
 The endoscopic picture varied slightly in the different cases, but the es- 
 sential form of the exaggerated infantile type was present. The author 
 has seen a case of congenital stridor from other causes. One caused by 
 papilloma was probably congenital, and one was certainly congenital. A 
 marked inspiratory stridor in another case was found to be due to the 
 collapse of the posterior membranous tracheo-esophageal wall into the 
 trachea as a result of the negative pressure in inspiration. This collapse 
 occurs normally to some extent in breathing and markedly in coughing 
 but not so markedly as seen in this case. It was an exaggerated form of 
 the forward movement of the posterior tracheal wall seen in Fig. 144. 
 In one case of thymic stenosis the stridor was marked but was of a less 
 croaking character than in the purely laryngeal form. In a number of 
 cases spasm was present in infants with the history of stridor having 
 been present, "ever since they were born," but as mentioned above, the 
 author considers it best to limit the name congenital laryngeal stridor 
 to the anomalous exaggerated infan.tile larynx. The diagnosis is very 
 readily made in a few seconds by the aid of the direct laryngoscope with- 
 out any anesthesia, general or local. In regard to treatment, direct 
 laryngoscopy has nothing to offer save that should asphyxia threaten, a 
 bronchoscopy would sustain life initil a tracheotomy could be done. .\s 
 a matter of fact, however, the author has never seen a case where the 
 symptoms were sufficiently urgent to demand this. If. however, the pa- 
 tient has a history of \ery severe suffocative attacks with cyanosis and 
 is not so situated that immediate tracheotomy can lie done, doubtless it 
 would be very much safer to have the tracheotomj' done as a preventive
 
 464 DIRECT LARYNGOSCOPY IN DISEASES OF THE LARYNX. 
 
 measure. All of the author's cases recovered completely within a year 
 by attention to the general health and especially careful feedings carried 
 out by the medical attendant. 
 
 Congenital zvcbs of the laryn.v and doubtless other malformations 
 may produce stridor. ()ne interesting case of the author is illustrated in 
 Fig. 9-i. At C is seen a tumor-like mass bulging upward from the vocal 
 cords of a child three months of age, which had had a crowing inspiratory 
 stridor since birth. The child was crying at the moment represented by 
 the sketch. Almost immediately afterwards the child took a deep breath 
 and what seemed to be a tumor was now very plainly seen to be a web 
 stretching across from, one vocal band to the other, and while it seemed 
 slightly below the cord in this position yet on phonation the band folded 
 upward into the tumor-like mass seen at C, Fig. 94. 
 
 Congenital goitre and congenital laryngeal paralysis of each of 
 which the author has seen one case, may cause congenital stridor but 
 these are better considered under stenosis.
 
 CHAPTER XXIX. 
 
 Bronchoscopy in Diseases of the Trachea 
 and Bronchi. 
 
 The field opened up liy Killian's demonstration of the ease and harm- 
 lessness of a careful bronchoscopy is so enormous and so new that thor- 
 ough, sxstematic, analytical consideration of it at the present time is im- 
 possible. Unfortunately, the trachea is a border line organ to which 
 heretofore relatively little attention has been given. The laryngologist 
 could, with his mirror, see a little of the upper portion but he seldom at- 
 tempted much in the way of study or treatment. The internist was more 
 interested in the deeper air passages and touched lightly upon it as of 
 little importance. The general surgeon rarely operated upon it except 
 to open it in tracheotomy or to amputate it in laryngectomy. The direct 
 method, however, has opened up a new field of study and the trachea 
 and its diseases will be systematically dealt with in the laryngologic text 
 books of the future. Delavan has called attention to the fact that the 
 earliest use of a direct method of endobronchial medication was carried 
 out by Horace (jreen in 18U, whose results were published in bonk form 
 in LSKI. 
 
 Iitdications for bronchoscopy in disease. Various indications may 
 be gathered from the hereinafter mentioned bronchoscopic observations 
 in the various diseases. But it may be well to emphasize a few of the 
 most clearly defined and urgently important indications. 
 
 I. .All cases of bronchiectasis should be bronchoscoped for foreign 
 bodies, for diagnosis and also for local treatment. Emil Mayer found a 
 foreign body in one case of bronchiectasis where its presence had never 
 been suspected. The author has foimd bronchiectasis present in two 
 cases of prolonged sojourn of a foreign body in the right inferior lobe 
 bronchus, though in botii of these cases the foreign body had been dis- 
 covered radiographically. 
 
 5. Every case of dyspnea, except, of course, pneumonia and similar 
 well understood conditions, calls for bronchoscopy.
 
 466 BRONXHOSCOPY IX DISEASFS OF TRACHKA AND BRONCHI. 
 
 3. Every case in which tracheotomy does not reheve the dyspnea 
 should be bronchoscoped to determine why the tracheal cannula does not 
 give relief. 
 
 4. All cases of hemoptysis which are not definitely proved to be 
 tuberculous should be bronchoscoped for diagnosis, and any severe 
 bleeding may be endoscopically packed as advised by Killian. 
 
 5. Even,' case of paralysis of the recurrent nerve the cause of 
 which is not positively known, calls for bronchoscopy. 
 
 G. In any case of thoracic disease in which any element of doubt 
 exists, valuable information may be gained by bronchoscopy. 
 
 7. In case of doubt as to whether bronchoscopy should be done or 
 not, bronchoscopy should always be done. 
 
 Contra'mdkaiions to broiichoscof^y in disease. The author cannot 
 recall any absolute contraindication to a careful bronchoscopy in any 
 case in which it is really needed. Unless there are urgent indications, 
 however, it had better not be done except for foreign bodies, in case of 
 aneurysm, high blood pressure, advanced heart disease, pulmonary tuber- 
 culosis. There are no valid contraindications whatsoever to bronchos- 
 copy in any case of obstructive dsypnea, provided, of course, the bron- 
 choscopist is prompt and certain in his insertion. 
 
 Anesthesia. Xo anesthesia is needed in children. In adults local 
 anesthesia of the lar)-nx is needed. Below this, for scientific study, it is 
 advisable to make at least one examination without any anesthesia, gen- 
 eral or local, because of the alteration of the picture by anesthesia. For 
 applications to the tracheo-bronchial tree mo-^t operators make an ap- 
 plication of a local anesthetic to the larynx. For this purpose, cocaine 
 is used by practically all endoscopists. If applications have to be fre- 
 quently made, the author would urge the use of extremely diluted solu- 
 tions and the trial of other local anesthetics and of no anesthetic. In no 
 case should the patient know the drug used for anesthesia. Additional 
 consideration of this subject will be found in Chapter I\'. 
 
 Position of the patient. The recumbent position is best for chil- 
 dren ; the sitting position for adults. For examination of a \ery dyspneic 
 patient, such as an asthmatic during an attack, the sitting ]iosition will 
 cause the patient less distress, though for obtaining scientific data, it 
 would be well, when possible, to examine the jiatient in both the sitting 
 and the recumbent posture. For endobronchial applications, the patient 
 should be in the sitting position in order to get the assistance of gravity 
 in diftusing the medication. For removal of excessive secretions "sponge- 
 pumping" in the recumbent posture is most promptly efficient. (For full 
 consideration of position see Chapter VI,)
 
 BKOXCIIOSlOl'V IX DISKASKS OF TRACHKA AM) I'.KONCIir. 407 
 
 Bronchoscopk appearances in disease. The variations of mucosal 
 color in health in difl'erent individuals and as influenced liy general and 
 local anesthesia, degree of ilhiniination. tubal contact, a him coating of 
 secretions, et cetera, as considered in Cha])ter IX. must be borne in mind 
 in endoscopy for disease. The first look should com[)rehend the color as 
 accurately as possilile over the entire visible area. With proper illu- 
 mination the ap|)earances in disease are readily recognized ])y the rhino- 
 laryngologist who is familiar with the appearance of various mucosal 
 pathologic changes. To appreciate morbid departures in form, it is 
 necessary to he familiar with the normal as seen under widely varying 
 conditions of age, movement, cough, etc. Bronchoscopists have, in the 
 variations of the form and movement of the bifurcation, a very valuable 
 means of contributing to the diagnosis of intrathoracic disease. The 
 carina trachealis in the normal chest moves forward as well as down- 
 ward during deep inspiration, returning on expiration. The auiiior has 
 noticed in addition to the above mentioned observation of Gottstein, that 
 the descent on deep inspiration is slow as compared to the quick return 
 in the following expiration, and furthermore, after the return there is a 
 distinct interval of repose which is longer thau tlie normal repose of 
 rhythmic respiration. To note this movement, it is necessarv that the 
 bronchoscope shou'd not be too near the bifurcation, as the instrument 
 itself will resist movement to a great extent. This normal respiratory 
 movement of the carina is of great diagnostic importance because it is 
 interfered witii liy various peri-tracheal and peri-bronchial conditions. 
 The fixation is .'.;reatest in cancer, somewhat less so in case of masses of 
 tuberculous glands unless these have sup])urate(l, and the movement is 
 only slightly interfered with in aneurysm. In fact, it is not usually no- 
 ticeable at all, unless the aneurysm is of enormous size. 
 
 Rxploration of the upper lobe bronchus is limited to the orifice and 
 a short portion of its stem, Init useful information may be gained from 
 the secretions seen to emerge. 
 
 lindobronchial treatment. Ingals wisely advises caution in the de- 
 velopment of endobronchial th.crapy. As pointed out by Kphraim and 
 others, ordinary oral inhalations of nebulized fluids are practically worth- 
 less for the local treatment of disease, for the reason that the nebula 
 does not penetrate even as far as the trachea. This has lieen proven ex- 
 perimentally on animals. Even where all the air inhaled by the patient 
 is saturated with finely nebulized fluid, it is doubtful whether any ap- 
 preciable amount reaches the deeper air passages, because of the im- 
 pinging upon the mucosa at the various turns of the upper air passages. 
 These various surfaces act as bafTle jilates to remove the minute particles 
 of medication suspcnderl in the air. Intratracheal injections with tlie aid
 
 4(iS BRONCHOSCOPY IN DISEASES OF TRACHEA AND BRONCHI. 
 
 of indirect lan'ngoscopy, have slightly better resuhs, but even then the 
 ])rompt coughing of the patient will remove the fluid before it can reach 
 the deeper passages, even when a large quantity of fluid is thrown in, 
 though of course the larger the quantity the greater the likelihood of its 
 reaching the bronchi. On the other hand, endoscopic applications place 
 the fluid deep down in the bronchi, where all bechic eftorts to expel it 
 only serve the better to scatter it over the mucosa. The most commonly 
 used method is with the endoscopic syringe with long metal nozzle in- 
 serted through the bronchoscope. Dr. Emma E. Musson of Philadel- 
 phia, has been using, with excellent results, a method which she demon- 
 strated before the meeting of the Pennsylvania State Medical Society 
 (Bib. 401). The larynx is exposed with the laryngoscope. A little of a 
 local anesthetic solution is applied to the interior of the larynx, and a 
 long silk-woven tube is passed through the larynx down into the bronchi. 
 The medicated solution is then injected with a syringe, the short nozzle 
 of which is inserted firmly into the proximal, funnel-like, silk-woven 
 tube. The placing of the head to one side will insure the silk-woven tube 
 going into the opposite bronchus, especially if a little curve is imparted 
 to the tube before insertion. This method seems, to the author, the very 
 Ijest, because the application can be made with accviracy and with very 
 slight annoyance to the patient. Of course, skill is required to be certain 
 of the accurate placing of the silk-woven tube in the desired bronchus. 
 
 Anomalies of the tracheobronchial tree. Anomalies of the tracheo- 
 bronchial tree are rare, but variations from what might be con- 
 sidered as an average type are noted by every endoscopist. Kahler (Bib. 
 300) reports two cases of diverticulum of the tracheobronchial tree 
 consisting of rudimentary Ijronchial branches. Guisez reports a con- 
 genital valve-like web obstructing part of the trachea. The dyspnea was 
 relieved by incision and dilatation. Congenital esophagobronchial and 
 esophagotracheal fistulae have been reported. 
 
 Deviation of lite trachea and laryngo ptosis. An interesting obser- 
 vation of the author is the coincidence, in two cases, of deviation of the 
 trachea with laryngoptosis. The author has seen a third case of laryn- 
 goptosis which also had a deviated trachea, but this was a case of can- 
 cer. .\s there was compression of the trachea, as well as deviation, by a 
 mass probably of infected mediastinal lymph nodes with involvement of 
 the esophageal wall, there could be no certainty that there had been a 
 previously existing deviation of the trachea. One case of deviation with 
 laryngoptosis with cervical ribs was reported (Bib. 2()9, pp. 77, 7'8 ). The 
 second patient was a woman of 32 years of age who came to the dis- 
 pensar}' for acute laryngitis, which, however, seemed to be in no 
 way connected with the ptosis of the larynx. The woman had never
 
 nuO.NCIIOSCOI'Y IN DISEASES OF TRACHEA AND BKONCIII. 
 
 ■iGi) 
 
 noticed llial her "Adam's ai)]>le" was any lower llian in other people. 
 She had heen subject to dyspnea on exertion ever since she could re- 
 member; but had not been particularlv subject to attacks of hoarseness, 
 such as that caused by the acute laryngitis for the relief of wdiich she 
 applied. .A bronclioscopy under local anesthesia showed the trachea de- 
 viated sharply backward, as shown at D, in diagram C, Fig. 404. The 
 patient was sent to Dr. Russell H. Boggs for a radiograph of the chest, 
 but tinfortunately she did not go and disappeared, no trace of her being 
 obtainable at the address gi\en on the dispensary register. All three of 
 these cases had, in common, the low position of the larynx, the thyroid 
 cartilage being submerged almost to the thyroid notch. The thyrohyoid 
 membrane was of about thrice the normal vertical extent, the necks m 
 the two women, cases A and C, being of usual length, the hyoid bone be- 
 
 B C 
 
 Fif;. 404. — Scluinatic illustration o[ three cases of laryngoptosis with deviation 
 of the trachea. A and C were probably congenital anomalies. B was associated 
 vvitli mediastinal cancer. In all three cases the larynx was almost entirely below 
 the notch of tlie sternum (S). FL, deviation forward to the left. BR, deviation 
 backward to the right. F, deviation forward ; IJ, backward. 
 
 ing only slightly lower than usual. The man's neck seemed (piite short, 
 the increased vertical extent of the thyrohyoid membrane apparently fill- 
 ing up all the space made by the ptosis of the larynx. In all, the trachea 
 was deviated, and in all the esophagus seemed to follow the trachea in 
 the deviation ; but it is necessary to eliminate case B from consideration, 
 because of the mediastinal malignancy which coinpressed the trachea 
 and involved the esophagus. In case A, the deviation was first forward 
 to the left and then backward to the right. In case C, the deviation 
 seemed to be directly backward immediately below the cricoid. The 
 carinal respiratory movements were normal in cases A and C. It is im- 
 possible for the author to express an ofinion as to whether these devia-
 
 -170 nRONXIIOSCOPY I\ DISEASK.S Of TRACHEA AND BRONCHI. 
 
 tions were congenital anomalies or not, though the fact of the cervical 
 ribs occurring in one case would rather speak for a congenital condition. 
 It will require a large series of cases to arrive at detinite conclusions. 
 The author had the honor of exhibiting case A to Prof. Killian upon his 
 visit to the author's clinic in 1907. 
 
 Deviation of the trachea from diseased conditions of surrounding 
 structures is quite common. In nearly every case of verv large goitre, 
 there is more or less deviation as well as compression. In substernal 
 goitre, the deviation is. in some instances, even more marked. Malignant 
 growths and glandular masses in the mediastinum are perhaps the most 
 common causes of deviation of the intrathoracic trachea, with aneurysm 
 standing next in frequency, in the author's experience. The differential 
 diagnosis of these conditions cannot be made, as a rule, on the endo- 
 scopic findings alone ; hut when taken in conjunction with the radio- 
 graph, the physical examination of the chest and the palpation of the 
 neck, the internist will usually be able to make the diagnosis with great 
 accuracy and will give due weight to the endoscopic findings of the 
 bronchoscopist. While not absolutely diagnostic, it is well to remember 
 that the infiltrations of carcinoma are usually very hard, imparting rigidi- 
 ty to the deformity and compressions of the trachea. It should also be 
 remembered that the level of the arch points strongly to aneurysm, that 
 the bifurcation is usually the seat of the enlarged masses of glands in 
 tuberculous processes, and that an esophagoscopy should always be done 
 in every case of tracheal deviation for the valuable light it will often 
 throw on the case. The author has observed in a case referred to him 
 by Dr. Baetjer nf Baltimore, de\iation of the trachea in an eight-year- 
 old boy who had a patent foramen ovale. 
 
 Compression stenoses of the traclica and Ivonchi. All of the dis- 
 eases mentioned as causing deviation may also cause compression. Goitre, 
 cervical or substernal, aneurysm and malignancy are the most common, 
 and may produce severe dyspnea. A goitre together with a mass of 
 mediastinal glands caused a compression of the entire cervical and tho- 
 racic trachea (Fig. 40V) in a leukemic (leucocytosis 62."),00IM bov of 
 seven years of age referred to the author bv Dr. John W. I'oyce for 
 tracheotomy. Not until the long, cane-shaped tracheotomic cannula en- 
 tered the right bronchus was the dyspnea completely relieved. The boy 
 died two days later, but not for want of air. Xo post mortem was ob- 
 tained. Com[)ression stenosis of the left bronchus is a not infrequent 
 condition in hypertroph}' of the cardiac auricle. In one such case the 
 author found the left bronchus almost closed and the esophagus so com- 
 pressed as to interfere seriouslv with swallowing. There was a i>osticus 
 paralysis of the left side of the larynx. The author has seen tracheal
 
 ERONCnOSCOI-Y IN DISEASES OF TRACHEA AND BRONCHI. 
 
 471 
 
 compression due to mediastinal emphysema caused by a fall down stairs. 
 Compression stenosis of the trachea associated with pulmonary emphy- 
 sema has been studied in thirty-two cases by Kahler (Bib. 21'G), who 
 notes that the stenosis becoming much worse on coughing explains the 
 frightful dyspnea from which many emphxsematous patients suffer. 
 
 The author saw one case of congenital tracheal stenosis due to 
 goitre. That it was an obstructive case of "blue baby" was recognized 
 by Dr. B. B. W'cclisler. I'rompt tracheotomy by Dr. S. Seegman, and 
 
 Fig. 405. — Compression stenosis of the entire cervical and thoracic trachea 
 by a goitre and a mass of glands in a lenkemic l)oy, seven years of age. The nar- 
 row whitish streak in the lateral view is the compressed trachea and the left 
 bronchus, the latter being displaced backward. The uncompressed right bronchus 
 is seen. Tracheotomy with a long cane-shaped cannula relieved the dyspnea. 
 (Author's case. Radiograph by Dr. George W. Grier.) 
 
 the u.se of one of the author's long tracheal cannulae saved the patient's 
 life. 
 
 The recognition of a compressive tracheal stenosis with its elliptical 
 or scabbard shape is quite easy. Of course, it must be recognized that 
 during cough there may be compression of lumen that would be misin- 
 ter()reted if not compared with the lumen during inspiration or at the 
 momentary rest period between expiration and inspiration. A concen- 
 tric funnel-like compression stenosis is exceedingly rare and occurs 
 onlv with annular growths coniplctelv siu-rmnuling the air tulic. To
 
 472 BROXCHOSCOPY IX DISEASES OF TRACHEA AND BROXCHI. 
 
 make certain that such a condition is really a pathologic and not a normal 
 narrowing, it is only necessary to remember that there is no narrowing 
 normally in the bronchi between branches. The walls of a suspected 
 narrowing should be searched for lateral branches and if none is given 
 oft and yet narrowing exists, we may conclude that it is pathologic, but 
 we must be on our guard not to mistake a perspective foreshortening 
 for a narrowing. In a marked compression stenosis of the trachea the 
 walls will entirely collapse during coughing. Normally the walls of the 
 larger bronchi and especially of the trachea do not collapse though they 
 may narrow slightly. In children they narrow very markedly, especially 
 the membranous posterior wall of the trachea, which advances so far as 
 to take up a considerable part of the tracheal lumen. The bronchi in 
 children narrow very markedly during cough, the narrowing in some 
 situations being concentric, in others scabbard like. 
 
 To measure the depth of a compression stenosis the beginning is 
 noted when the tube mouth has reached the first observable narrowing. 
 Then the tube is inserted until it has passed entirely through the stenosed 
 area and arrives at a lumen of normal size and contour, then the depth 
 is again noted. By using very small tubes in tight stenosis it is easy 
 in any case to measure depth in this way, though, of course, if preferred, 
 olivarv bougies such as used for esophagoscopic dilatation may be used 
 with the sense of touch as a guide as to the engaging of the olive and its 
 emergence on the other side. By either method the measurement should 
 be repeated on withdrawal. Comparison of the two measurements will 
 minimize error. 
 
 Treatment of compression stenoses of the trachea consists in tra- 
 cheotomy. Literature is full of cases unrelieved by tracheotomy simply 
 because the ordinary tracheotomic cannula of the shops will not reach l^e- 
 low an extensive compression. It requires, in most cases, the author's 
 long cane-shaped cannula as described under ■"Tracheotomy" (See also 
 Fig. 407). The treatment of compression stenosis of the bronchi con- 
 sists in the use of the long cane-shaped cannula, if the stenosis is near 
 the main bronchial orifice. If deeper the intubation tubes used for 
 cicatricial stenosis of the bronchi may be used (Bib. "269, p. 79). Their 
 use is indicated only when the stenosis is so great as to interfere with 
 escape of secretions from the subjacent air passages. 
 
 Permanent cure will, of course, depend upon the curability of the 
 compressive mass. 
 
 Thymic compression stenosis. The author has demonstrated bron- 
 choscopically (Bib. 255 and 2G9) that the enlarged thymus can and does 
 in some instances compress the trachea even to the point of asphyxia. 
 Four cases of thvmic tracheostenosis have convinced the author of the
 
 BKOXCHOSCOPY IN" DISKASKS OF TRACHKA AM) liKONCIII. 
 
 473 
 
 purely mcch.-mical CDiulitioiis ])rescnt in cases of tliymic liypertroi)hy ; 
 and having seen so many illustrations of extreme danger of anesthesia 
 m even the slightest stenosis of the trachea, he feels convinced that the 
 thymus deaths attributed to "status lymphaticus" and "hyperthymiza- 
 tion of the blood" are really nothing more or less than arrested respira- 
 tion, which is, as usual, fatal because respiration when arrested by ob- 
 struction cannot be started again without either tracheotomy or bron- 
 choscopic oxygen insufflation. The author would strongly urge that 
 when respiration ceases during anesthesia and cannot be immediately 
 started, tracheotomy should be done, a long cane-shaped cannula in- 
 serted, and amyl nitrite insufflated into the trachea. I'.ctter still would 
 be the insufflation of oxygen through the bronchoscope, or through the 
 intratracheal insufflation catheter. These are not always promptly avail- 
 able. Inn tracheotomy can always be done in a few seconds. A slight 
 degree of dyspnea may never be noticed, and mav quite readily be at- 
 
 FiG. 40!i. — From a photograph of a specimen frmn a ncw-licirn infant as- 
 phy.xiated by compression of the trachea at A by the large fourtli lobe, T, of tlic 
 thymus gland. (Case of Dr. V. L. .Andrews.) 
 
 tributed to enlarged tonsils or adenoids. The excitement of starting the 
 anesthetic can very readily engorge a vascular structure, like the thymus 
 gland and the increased bulk compressing the trachea produces apnea 
 just as soon as the patient begins to go under the anesthetic. Artificial 
 respiration, as ordinarily done, is absolutely useless in the presence of 
 c\en very slight degrees of tracheal stenosis. Air can be forced out of 
 the lungs, but it cannot be drawn in. It is a well known fact that en- 
 gorgement of tissue like the thymus gland increases its bulk. If the 
 hypertriijihic gland can compress the trachea, the engorged liypertro[]hic 
 gland can cfimjiress the trachea still more. After death, the congestive 
 part of the bulk may diminish so as not to be noticeable. .\ beautiful 
 auloi)tical confirmation of the above mentionetl, jireviouslv published 
 observations of the author on the purely mechanical nature of thynnis 
 death is aft'orded by Dr. \'. I-. Andrews' case. A new born child died 
 after making a number of virilent ineffective inspiratory mu\cments.
 
 474 
 
 BRONCHOSCOPY IX DISEASES OF TRACHEA AND BRONCHI. 
 
 Autopsy revealed a very large four-lobed thymus. The fourth and com- 
 pressive lobe. T. was compressing the trachea at the end of the dotted 
 line, A, Fig. -iOG. Dr. Andrews' report is as follows : 
 
 "The thymus is short and thick and contains four lobes. It meas- 
 ures 4 cm. in length, 3..") cm. in width. l.T-") cm. in average thickness. 
 There is a right, left and middle lobe. The left lobe is small. The fourth 
 
 Fig. 407. — Thymic traclieostenosis temporarily reliesed with the author's 
 long cane-shaped tracheal cannula. The shadow of the hypertrophied thymus 
 shows to the right of tlie cannula, and especially strongly at the right of the lower 
 end. (Authors' case.) 
 
 lobe extends from beneath the lower ends of the right and midille lobes 
 upward and outward, at an angle of 45". into the right pleural cavity for 
 a distance of 1.5 cm. The upper end is free in the pleural cavity and is 
 covered by a thin movable membrane (pleura?). The lower end of this 
 lobe lies over the trachea beneath the lower part of the middle and right 
 lobes and at this point, 1 cm. above the bifurcation of trachea, the thymus 
 measures 2 cm. in thickness. Here the trachea presents a flattened ap-
 
 HRONCHOSCOPY IN DISKASKS 01* Tlt.\CHI-A AND RRONCIII. 
 
 475 
 
 pearance antero-postcriorly. more marked on the right side than on the 
 left." 
 
 In tln-ee of the anthor's cases the compression was from before back- 
 ward. In the last case it was lateral ihe axis of the scabbartl-like lumen 
 being from the left posteriorly to the right anteriorly. 
 
 As shown by FetterhotT and Gettings (quoted by H. C. Clark) com- 
 pression of the trachea may occur from a left innominate vein engorged 
 by an embarrassed right heart, the dilated vein being forced to extend 
 I)OStcriorly because braced anteriorly by the thymus. Treatment of thy- 
 
 Fk;. 408.— riiol(ij;r;ipli 
 mopexy. ( .Author's case.) 
 
 )f a child of two vears taken si.x months after thy- 
 
 mic compression stenosis is the same as mentioned for other tracheal 
 compressions, namely the cane-shaped cannula of sulhcient length to 
 reach below the compression (Fig. in?). As the author has 
 pnnen, hypertrophic thymus is dangerous solely from a mechanical com- 
 I)ressive pomt of view. I le who will see that a good respiratory channel 
 is mechanically maintained need not worry about such purely hypothet- 
 ical conditions as "hyperthymization of the blood," etc. Having tempor- 
 arily i-arcd for the compression stenosis by tiie insertion of the long can- 
 nula, the next step is either thymopexy nv thymectomy (subtotal). In 
 the author's first cases all of tlie gland that could be brought up was 
 shelled oiU of its capsule anil remo\ed. In the last case an (.•<|u.'dly sat-
 
 476 BKOXCHOSCOPY IN DISEASES OF TRACHEA AXD BROXCIII. 
 
 isfactory result was obtained by thymopexy. This last case was as fol- 
 lows : 
 
 Robert C, aged two years, was referred to the author by Dr. W. H. 
 Wesley for dyspnea and noisy breathing of three montlis' duration. All 
 of the accessory respiratory muscles were working vigorously. The 
 suprasternal and clavicular fossae were indrawing and there was a typi- 
 cal '"trichter brust" at each inspiration. Bronchoscopy rexealed a tracheal 
 compression reducing the lumen to a narrow chink whose curved axis 
 was from the left posteriorly to the right anteriorly. Tracheotomy was 
 done under infiltration anesthesia and the enormous thymus bulged large- 
 ly into the wound. It was drawn upward and stitched with linen to the 
 tendons of sternomastoid muscles and to the skin and tissues at the top 
 of the sternum. The tracheal cannula was removed on the eighth day and 
 the child was discharged well on the fifteenth day. There had been no 
 return of the dyspnea when the photograph, Fig. 408, was taken six 
 months later. 
 
 Remarks. The lateral compression visible endoscopicallv has not 
 previously been observed. From this one case it is not wise to conclude 
 that thymopexy is to be preferred in all cases to subcapsular subtotal 
 thymectomy. Doubtless part of every very large gland should be re- 
 moved. Total removal is probably impossible even if desirable. An 
 able article with a report of fifty operated cases is written by Parker 
 (Bib. 428). See also a valuable contribution by Schwinn, Bib. 490. 
 
 Inflammations and their sequelae. Chronic circumscribed tracheo- 
 bronchitis is a common affection in adults. Acute circumscribed tracheo- 
 bronchitis is rather frequent in the course of influenza, (q. v.) as mani- 
 fested by the dry, barking cough and severe burning pain back of the 
 sternum. In children an occasional interesting complication is seen in 
 the form of laryngeal spasm, doubtless a reflex from an irritated tracheal 
 mucosa, dift'ering from the ordinary diffuse bronchitis in that the im- 
 portant lesion is limited to, or at least most marked in, the trachea and 
 larger bronchi. In some instances it is limited to a portion only of the 
 mucosal area of these passages. A case of chronic purulent bronchitis 
 is described in the subsequent paragraph on tuberculosis. Non-tuber- 
 culous abscess of the lung has been found and evacuated bronchoscopic- 
 ally (Bib. 271) by the author. The bronchoscope in relation to another 
 case of pulmonary abscess is shown in Fig. 13fi.* Freudenthal records 
 non-specific ulceration of the bronchial mucosa in one case. Ephraim 
 reports nineteen relative cures of chronic bronchitis out of 23 cases. In 
 many in.stances, a single application only, was necessary. The applica- 
 tions were followed by increased expectoration and a total change of 
 
 •As stated by George L. Richards, a non-tuberculous pulmonary ab."5cess 
 justifies the suspicion of foreign-body origin.
 
 BRONCHOSCOPY IN DISKASES OF TRACHEA AND ISKOXCIII. 477 
 
 secretions. The solutions used were novocain and suprarenin dissolved 
 in salt solution in some instances, and in others in a five per cent solution 
 of potassium or ammonium iodid. The ammonium iodid was used espe- 
 cially in the dry form of bronchitis, and a few drops of iodine were added 
 to it. In a number of cases he also used weak solutions of argentic 
 nitrate. In two cases of chronic purulent bronchitis, permanent healing 
 was accomplished by repeated insufflation of turpentine emulsion to 
 which suprarenin had been added. In one case each of chronic pneu- 
 monia and of double gangrene of the lung, the procedure was ineffective. 
 Bronchiarctla and bronchiectasis. Bronchial stenoses comprise a 
 number of different lesions. The chief causes of cicatricial bronchial 
 stenosis are traumatism, syphilis and tuberculosis ; or, perhaps, more ac- 
 curately, the secondary infections complicating these lesions. Tuber- 
 culous processes are of such slow progress, as a rule, that the lung ac- 
 commodates itself to the altered conditions, and cicatricial bronchial 
 stenoses secondary to tuberculosis rarely require local treatment, though 
 they do occur as the result of erosion through the bronchial wall. The 
 author has seen si.x such cases. Cicatricial stenoses, in some instances, 
 may require dilatation in order to secure proper drainage of the infra- 
 strictural bronchiectatic cavity, and thus cure the patient of bronchiectasis 
 with its distressing cough, foul expectoration, dyspnea and lesser symp- 
 toms. For syphilitic strictures it may be necessary to use prolonged in- 
 tubation with bronchial intubation tubes, put in place with the aid of the 
 bronchoscope and left in situ for a period of from one to seven days. 
 The tube should be left for a few hours in case of daily removals, or 
 a few days in case of weekly removals. Extubation is performed with 
 an extubator used through the bronchoscope. In order to obtain a suffi- 
 cient lumen for the insertion of the intubation lube, a laminaria or tupelo 
 tent may be used, placed in situ with the author's instrument for the pur- 
 pose (Rib. 2(!!)). The tent is open to the objection, that it obstructs all 
 drainage for the time it is in place, though this need be for only a few 
 hours. Divulsion, as hereinafter described, is the best method by which 
 to obtain a suflicient iunien for intubation, and even if some trauma re- 
 sults from divulsion, cicatricial tissue is not readily infected by the or- 
 ganisms present to which the patient is already more or less immune. 
 Endobrtincbial neoplasms mav cause bronchiectasia. This is an addi- 
 tional reason for bronclioscojiing every case with bronchiectatic symptoms. 
 P.ronchiectasis and bronchiarctia resulting from foreign bodies are con- 
 sidered in Chapter X\'l. Cicatricial stenoses of the lironchi are \ery 
 readily rccognizt'd by tb.e cicatricial nature of their walls with a total 
 absence of rings. This condition, of cr)urse, may be more or less con- 
 fused l)v inlbmnnatory states wl;icli urdinarily mask the view of rings.
 
 478 BRONCHOSCOPY IN DISEASES OE TRACHEA A\D BRONCHI. 
 
 Any one familiar with the neat, clear, sharp edges and more or less 
 oval lumen of the openings into bronchial branches would never mistake 
 these when covered with normal mucosa for the lumina of stenotic 
 bronchi. Until the sense of gauging depth with one eye, only, has been 
 acquired by practice perspective foreshortening of the image may be mis- 
 taken for a gradual narrowing of the lumen. Emma E. Musson ( Bib. 401) 
 reports excellent results in the endnscopic treatment of bronchiectasis, 
 by injection as above mentioned, of a dram of freshly prepared 2o per 
 cent argATol solution. Gereda advises hydrogen peroxid injections. Eph- 
 raim's medication is mentioned at the beginning of the chapter. 
 
 Bronchial asthma. The literature of bronchial asthma is a wilder- 
 ness of theory. The reason for this is that our knowledge at present 
 rests upon no foundation of morbid anatomy, because the autoptical find- 
 ings are inconclusive, but we have evidence that there is a living morbid 
 anatomy to be studied bronchoscopically, and the author would urge all 
 bronchoscopists carefully to study, during the attacks, every case of 
 asthma available. If this be done, bronchoscopic accomplishment here 
 promises to be second only to that in the field of foreign body extractions. 
 The author advises the ignoring of the assumption of "irritation of the 
 respiratory center," "asthmogenous points," "spasm of the muscles in 
 the bronchial walls," "swelling of the bronchial mucosa," and all the 
 other previously accepted statements as to the conditions. It is absolutely 
 necessary to start in with the mind blank to previous theories and simply 
 observe and record the bronchoscopic pictures in about 1,000 cases. In 
 order to get an accurate picture, it is necessary that this be done without 
 anv anesthesia, general or local, in at least one of the sittings with each 
 patient, in order that the bronchoscojiic picture shall not be altered by the 
 application of the local anesthetic; for it is well known that applications 
 of cocaine to anv part of the air passages, even abo\e the larynx, will 
 modify an asthmatic attack, and, therefore, in all probability, would alter 
 bronchoscopic appearances. On the other hand, irritation of the bron- 
 choscope acting as a foreign body, excites reflexes which may also alter 
 the endoscopic picture. For these reasons, controlled observations with 
 and without anesthesia are necessarj-, and they should be separately re- 
 corded, making a number of observations each way. In this manner, we 
 may record a living morbid anatomy for asthma. The bronchoscopic 
 picture in asthma during the attack is variously reported by different 
 observers in different cases. Xowatny observed redness and swelling 
 of the bronchial mucosa. Galebsky reports redness and edema limited 
 to one area. Horn reports a spasmodic stenosis simulating a cicatricial 
 stenosis, which was foimd, at a later bronchoscopy, to have disappeared. 
 The author has been able to observe onlv two cases during the attack.
 
 BRONCIIOSCorY IN DISKASKS 01" TK.\CIII:a AND BROXCIII. 47!J 
 
 In iieitlier of these was lie able to make out spasmodic stenosis, and the 
 color of the mucosa was more purple than red. The bronchi were all 
 filled witii secretions and the patient's distress was completely relieved 
 by the bronchoscopy with removal ot secretions without any application 
 of any kind, tlie bronchoscopy being done without any anesthesia, gen- 
 eral or local. The findings and the results were the same in both in- 
 stances. Both [latients had a recurrence of their attacks at about the 
 Usual intervals, no medication havin;.: been used. All the foregoing ob- 
 servations by the ditferent observers were during the attacks, and they 
 all go to show that there is a very varied bronchoscopic picture. Be- 
 tween the attacks, the pictures observed bv most of the observers have 
 been normal, except in some cases where unusual dilatation of the vessels 
 has been observed. I'Veudenthal records the appearance of a scar-like 
 mass obstructing the entire lumen of the bronchus. The obstruction was 
 overcome by the local application of a 20 per cent solution of cocaine, 
 liberating an enormous discharge of secretions. In another case adrenalin 
 was used with excellent results after the air passages were cleared of 
 secretion. One of his patients was practically cured, remaining perfectly 
 well and free from attack at the end of six months. In this case, an 
 emulsion of orthoform a? follows was used: 
 
 Orthoform (>.5 
 
 :\Ienthol 0.5 
 
 Formalin 0.5 
 
 Ol. amygdal. dul. 15.n 
 
 Gum acac. 10.0 
 
 Ac|ae ad fiO.O 
 
 M. F. Enuilsif). 
 .\bout locc. was injected twice weekly for ten applications. Then 
 during an intermission of the treatments, after the great excitement of 
 being exhibited at a medical meeting, a severe recurrence took ])lace. 
 After ten more treatments the attacks ceased and the patient was still 
 well at the end of six months. The jiatient, a young man of 27, had had 
 asthma since cliildJKKjd and ;ill i>\ tin members of his mnther's family 
 were asthmatic. He had never been able to slecj) an entire night rest- 
 fully. In another case, Frendenthal used propacsin instead of orthoform 
 in a like am(}unt. The applications were made in the morning \\ ith stoni.icii 
 empty. ( )ut of a total of 1.3 patients, b'reudenthal considered S cured, 
 3 improved and 2 not benefited. Ephraim reports 1 •'>■'! cases of 
 asthma treated endolironchially with a spray of su|irareuin with novo- 
 cain with excellent results. .\ long-tubed bronchosco])ic atomizer was 
 used. In most cases free expectoration resulted within the following 
 twelve hours. The results were not so good in the spasmodic dry asthma.
 
 480 BRONCHOSCOPY IN DISEASES OF TRACHEA AND BRONCHI. 
 
 nor in cases in which neurasthenia predominated. Results also were not 
 fa\orable in cases in which immediate rehef of the attack did not follow 
 the application of the solutions injected during the attack. Of the 88 
 cases in which ultimate results were known, 73 were recorded as good. 
 Of these, 48 were free from recurrence, some of them as long as 1^4 
 years. Most of these were of the most severe type in which scarcely a 
 night in years had passed without an attack. In seven other cases the 
 attacks were notably milder and at longer interv'als, the permanent dis- 
 tress less, without, however, permanent cure. Ephraim thought these 
 effects were due to medicinal action of the substance injected, and not 
 to any mechanical effect, because he had observed that the injection of 
 normal salt solution alone produced no objective changes, and a patient 
 showing diffuse bronchial rales before insufflation, showed, after in- 
 sufflation, a vanishing of the rales on the side which had been treated. 
 In none of the 133 cases had there been any untoward effect. As pointed 
 out by Dr. James Adam in one of the best practical works on asthma 
 that has ever appeared (Bib. 3), asthma in most cases is essentially a 
 toxemia and no treatment can be successful without recognition of this 
 element in the etiology. 
 
 influenzal tracheitis. Of all forms of tracheitis, perhaps the least 
 frequently dilTerentiated as a morbid entity is influenzal tracheitis. When 
 the author observed his first cases in the prebronchoscopic days (1889) 
 he believed that he had discovered a new disease. Indirect methods 
 yielded few and uncertain pictures of the tracheal lesions, and, indeed, 
 none in the most interesting class of cases, namely those occurring in in- 
 fants and children. The advent of direct methods of examination per- 
 mitted of accurate observation of the clinical appearances of the tracheo- 
 bronchial mucosa. A very good illustration made from the author's 
 color drawing of one of these cases has been published (Bib. 243). The 
 clinical appearances might be classified vmder a number of dift"erent 
 types, but it has seemed to the author that the differences he has ob- 
 served are reallv different stages of the same disease. The first stage 
 has much the same appearance as in influenzal inflammation of the nasal 
 mucosa at the same stage. The tracheal mucosa is reddened. Its color 
 deepens. Swelling of the mucosa begins. Later, an exudate forms, at first 
 serous, then mucoid, then purulent and finally thick, tenacious and exceed- 
 ingly difficult of expectoration even by the robust adult. In infants who 
 naturally are almost incapable of expectoration, death may occur from 
 inability to rid the air passages of secretion and drowning of the patient 
 in his own secretions (q. v.) may be threatened. The bronchi or even the 
 trachea itself may be occluded by mucosal swelling, or edema, actually 
 causing death by the stenosis. Both these conditions are inde|ien(lent of
 
 BRONCHOSCOPY IN DISK.\?i;S OF TRACHKA AND KRONCIII. 481 
 
 hroncho-pneumDnia. which may nr may not exist. Tlie author has observed 
 blood-clots on the surface of the inflamed membrane, without true hemor- 
 rhage, similar to those in nasal influenza, first described by D. Braden Kyle. 
 Superficial erosions of the tracheal mucosa have been seen by the author 
 in a number of cases. There was in no case any true adherent mem- 
 branous exudate, on which alone the difl:'erential diagnosis rests. Clini- 
 cally a severe case of influenzal laryngo-tracheitis cannot be differentiated 
 from diphtheria, as it presents the same clinical picture, even to the 
 adynamia. Direct inspection showing abscess of a fibrous exudate will 
 I)romptly decide, and corroboration by the laboratory from the specimens 
 bronchoscopically removed will follow. A bronchoscope need not be 
 inserted below the larynx. The glottis may be propped open with the 
 tube mouth (supraglottic tracheoscopy q. v.) or often the trachea can be 
 clearly seen by use of the laryngoscope alone. In some instances, there 
 seemed to be but little laryngeal inflammation, the croupy cough being 
 probably due chiefly to spasmodic conditions excited by the inflammation 
 below. The laboratory is seldom of aid if only secretions from the 
 l)har\nv are sent. If the secretion is obtained by direct methods from 
 the trachea, a reliable report nearly always can be had from specimens 
 taken through the sterile bronchoscope which prevents contamination 
 with organisms. A typical case mav be cited: 
 
 The author was called to see an infant, aged seven months, suftering 
 \\ ilh extreme ins])iratory dysjjuea, with croupy cry and stridulous breath- 
 ing, but no cougii. The onset had lieen gradual, not nocturnal or sudden, 
 two weeks before, .\ntitoxin had been given without relief. Pneumonia 
 had been excluded l)y Dr. Royce and laryngismus stridulus b\' an able 
 laryngologist. who. however, jjointed out to us evidences of a certain 
 element of spasm in the case. Temperature, 103": pulse, 1110 : respira- 
 tion, 32. The first glance at the larynx through the direct lar)-ngoscoi)e 
 showed it to ije free from edema or other obstruction or even active in- 
 flammation. When the bronchoscope was introduced, there was absolutely 
 no cough, (no anesthetic used) and during the entire examination, last- 
 ing about five minutes, there was not one single effort to cough. The 
 tracheal mucosa was intenselv inflammed. and there was a tenacious 
 secretion adherent in scattered locations. This secretion was wiped away 
 readily, leaving no erosion nor bleeding. The bronchial mucosa was in- 
 tensely inflammed in all the larger tubes : the smaller tubes were ob- 
 structed with pus which was moved to and fro in the respiratory current, 
 but there was no coughing efi'ort to expel it. Smears made from the 
 sterile swabs passed through the sterile bronchoscope, showed an abun- 
 dance of influenzal organisms (Dr. Ernest W'illets). There was a little 
 streak of pus extending upward betw'een the arytenoids, and out over
 
 482 BRONCHOSCOPY IN DISEASF.S OF TRACHEA AND BRONCHI. 
 
 the upper edge of the party wail. No anesthetic, general or iocal. was 
 used and the child seemed in no way inconvenienced by the bronclio- 
 scopy. Tlie child made a slow hut complete recovery. The interesting 
 points about this case are the inspiratory dyspnea without laryngeal ob- 
 struction ; the total absence of the cough reflex; the severe tracheo-bron- 
 chitis without pneumonia ; the ease and certainty with which the laryn- 
 geal diagnostic question can be decided by direct laryngoscopy. It is in- 
 teresting to consider what became of the endobronchial secretion. The 
 interarytenoid streak was evidence of unimpaired ciliary activity, so that 
 it seems probable that a portion of the pus was expelled in this way, the 
 remainder being absorbed. The secretions in some instances require 
 aspiration to save life. Absence of the cough reflex in influenzal trache- 
 itis is seen only in infants, and is not present in ever}' infantile case. 
 
 The dro7vning of the patient in his own secretions. (Bib. 232). 
 When tracheal and bronchial secretions are in excess of the amount re- 
 quired properly to moisten the inspired air they become a menace to life 
 unless removed. Under almost all circumstances the normal activities of 
 the cough reflex, forced expiration, and ciliary action remove these secre- 
 tions. There are certain circumstances, however, under which these 
 normal agencies are inefficient. \^arious drugs, especiallv anti-bechics, 
 hinder the action of the normal agencies ; hence should always be avoid- 
 ed. The writer has always opposed their use in all laryngeal and tracheal 
 surgery and in bronchoscopy. Doubtless many of the post-anesthetic 
 pneumonias in surgery remote from the air passages, have been due to 
 the abolition of agencies by which secretions are normally removed from 
 the air passages. Perhaps the most frequent etiologic factor in the fail- 
 ure to rid the air passages of secretion is age. An infant cannot ex- 
 pectorate and is surprisingly inefficient in getting secretions out of air 
 passages even as far out as the laryngo-pharynx. Adults as well as 
 children when dying often fill up with secretions which they are too feeble 
 to expectorate, and in some instances, by the failure of the respiratory 
 blood changes, drowning is the final mechanism of mortality in death 
 primarily due to disease remote from the air passages. The complex 
 physiologic co-ordinated mechanism by which secretions are normally 
 removed is too lengthy to be entered upon here ; but disturbances of 
 laryngeal motility and in the author's experience, bilateral cadaveric 
 paralysis especially, are frequently associated with the condition which 
 the writer has termed the "drowning of the patient in his own secre- 
 tion." One of these cases seen many years ago at the Western Pennsyl- 
 vania Hospital with Dr. Clarence Ingram was an excellent illustration. 
 A woman, aged forty years, was dying of general lymphosarcomatosis. 
 Pressure from the mediastinal or cervical iieoplasmata produced a bi-
 
 BRONCHOSCOPY IN DISKASKS OK TRACHKA AND BRONCHI. 483 
 
 lateral cadaveric paralysis. The level of the frothy tlnid could be seen 
 rising and falling first in the main bronchi, then higher and higher in the 
 trachea until the level of the upper laryngeal orilice was reached. The 
 woman could not expectorate. Had she not had other conditions and 
 lesions, it would have been easy to have ])rolonged life indefinitely so 
 far as drowning was concerned by the bronchoscopic aspiration of the 
 fluid. The author has done this in other cases with the result of saving 
 the patients. Before the days of bronchoscopy, he did a few tracheotom- 
 ies for this purpose with excellent results; secretions could then be 
 readily removed by a nurse trained in tracheal work — secretions that 
 could never have been expectorated. In children, Dr. Boyce's method 
 of assisting expulsion of tracheo-bronchial secretion by holding the child 
 up by the heels has often proved efficient and has tided over a dangerous 
 period. Perhaps the most important class of cases is that in which the 
 secretions due to traumatism or irritation of a foreign body in the lower 
 air passages gradually accumulate and as])hyxiate the patient. One of the 
 only two tracheotomies (in previously normal cases I done l>y the author 
 for dyspnea after the removal of the foreign bodies, would not have been 
 needed had he known what he has since discovered, namely, that chil- 
 dren feeble from prolonged respiratory efifort, will in some instances and 
 after certain kinds of foreign bodies, fill up with tracheo-bronchial se- 
 cretions and will die if not relieved. It would seem that some of the 
 instances rei)orle(l by various writers in which children have died in an 
 unex])lained manner after the removal of foreign bodies may be ac- 
 counted for in tliis way. The condition was first pointed out to the au- 
 thor a number of vears ago by l^r. KUen |. i'atterson. I'erhaiis the best 
 case to cite as an illustration is the following: 
 
 John K., aged six years, referred to the author by Dr. Wagner. 
 Prior to coming under the care of Dr. Wagner, the chilcl had gone 
 through the usual treatinent by antitoxin and (piarantine for a croupy 
 cough with temj)erature elevation, due to a beech-nut hull, which had 
 been cast about in the trachea and bronchi for three weeks. A grayish 
 apiicarancc of the skin due to dyspnea favored the diphtheritic diagnosis. 
 The beecii-nut hull and a large quantity of secretion were removed at the 
 Presbyterian Hospital, by ijronchosco])y. 'I'liat night the patient be- 
 came extremely dyspneic and cyanotic. Bronchoscopic removal of a 
 large quantity of thick viscid secretion gave complete relief. There was 
 a less severe recurrence of the symptoms the next night but the chil<l 
 had then rallied enough to rid itself of secretions which were moreover 
 less tenacious. The child made a rapid recovery. 
 
 There have been twelve of these cases in tlie j)raclico of Dr. I'attor- 
 son and the autlmr. In simie the aspiration of secretion was sul'licienl ;
 
 484 BRONCHOSCOPY IN DISEASES 01' TRACHEA AND BRONCHI. 
 
 in two instances tlie administration of oxygen through the bronchoscope 
 after the removal of the secretions saved life. For this the bronchoscope 
 with the anesthetic attachment of Dr. T. Drysdale Buchanan was found 
 very convenient as it permitted of the slightest interruption of the 
 flow of oxygen during the removal of secretions by "sponge pumping." Tn 
 one instance the swelling of the mucosa, in other words the serous 
 exudate into the mucosal tissue, prevented the pulmonic interchange of 
 gases ; the oxygen passed down through the bronchoscope could not be 
 taken up and the child died. This was a case of influenzal tracheo 
 bronchitis complicated by pneumonia. It was not a foreign body case. 
 In one instance the secretions of an influenzal tracheitis were so gelatin- 
 ous as to rec|uire removal with forceps. In some of the cases the se- 
 cretions were so viscid the_\- could not have been drawn through any 
 form of tubal aspirator. 
 
 Bronchoscopy for the relief of jiatients threatened with drowning 
 in their own secretions is a new and important held of usefulness for 
 the bronchoscope as an aid to general medicine and surgery. 
 
 Since the foregoing was written a number of confirmatory observa- 
 tions have been made by others, notably by Carpenter ( IHb. li!)). 
 
 Gangrene of the lung. Guisez reports a case of pulmonarv gan- 
 grene of verv grave prognosis cured by intrabronchial injection of 
 guiacol in oil with occasional injections also of iodoform suspended in 
 oil. Jqjhraim's results were unfavorable. 
 
 Jneiirysm. It is probable that bronchoscopy will repeat the historj' 
 of the Roentgen ray — aneurysms will seldom be overlooked, but will 
 often be diagnosticated when absent. The ordinary normal aortic im- 
 pulse is most astonishing. It is only after repeated examinations that 
 one grows accustomed to it. Any thoracic tumor compressing the bron- 
 chus may show a transmitted pulsation. In one case, that of a woman 
 of 50, there was distinct stenosis from external pressure, with an im- 
 pulse that seemed expansile rather than merely transmitteil. Study of 
 the symptoms practically negatived the suspicion of aneurysm. The pa- 
 tient was a neurasthenic and had the palpable relaxed abdominal aorta 
 so common to that class (Boyce). It seems highly probable that her 
 bronchial compression was due to a similar condition in the thoracic 
 aorta. An aneurysmal sac may transmit little or no jnilsation. The fact 
 that a bronchoscopically or esophagoscopically visible bulging ])ulsates is 
 far from conclusive evidence of aneurj'sm. It is a frequent error to as- 
 sume that the siiape and position of the in-bulging is indicative of the 
 location of the ])eritracheal compressive mass. It must not be assumed 
 that because the apparent bulging is from behind that it cannot be an 
 aneurysm of the aortic arch. Tlie compression may be applied in front
 
 nROXCIinSCoPY in DISEASKS Ol" I'RACIIFIA AM) I'.RONCHI. 485 
 
 or at the side. and. yet. Iieeause of tlie posterior deticiencv of the traclieal 
 cartilage, the endoscopic ajijiearance may be that of compression from 
 behind. Often lateral compressions may be misleading in the same way. 
 The author has examined endoscopically quite a number of cases of 
 aneurysm, and occasionally has been able to make a diagnosis ; but as a 
 rule, he does not regard either bronchoscopy or esophagoscopy, when 
 negative, as reliable a means of diagnosis as the fluoroscope. He does 
 not advocate endoscopy as a means of diagnosis of esophageal disease 
 until after aneurysm has been excluded by the fluoroscope and the well 
 known clinical methods. Kahler advises the relief of dyspnea in aneurys- 
 mal compression of the trachea or bronchi, by bronchoscopic dilatation. 
 Von Eicken disagrees with this view, as does also Taimz. Mr. Waggette 
 (Rib. oG7 ) rejjorts the obser\ation of the wall of an aneurysm which 
 had caused absor])tion of the tracheal rings. 
 
 I. lies of the triichcD-bronchial tree. Considering the frequencv of 
 luetic lesions in the larynx their rarity in the lower air passages is re- 
 niark;ib!e. Tossibly they are more frequent than supposed. The author 
 has seen a fev\- cases (Bib. 243^, and other bronchoscopists ( \'on Eicken, 
 Kahler ) many more. The lesions may be gummatous, ulcerative, or 
 innanimatory or may be compressive granular masses. Excision of the 
 margin of ulcers or fungations for biopsy is advisable, and in anv event 
 the therapeutic test and the exclusion of tuberculosis will be required for 
 confirmation. Ilenioptysis in three cases pre\i(iusl\- diagnosticated as 
 tuberculous was found bv the auth<ir t'l come from a lentic lesion in the 
 lower air passages. 
 
 Bronchoscopy in tiihrrciiinsis of the tiacheo-hroiniiial tree. It is 
 much to be regretted that tuberculosis has not received the amount of 
 endoscopic study that the scientific value of the data thus obtainable 
 would warrant, 'i'lie author's own observations lead him to describe the 
 following endoscopic picture below the larynx. The subglottic infiltra- 
 tions from extensions of laryngeal disease, are usually of edematous 
 appearance but are much mure tlrni than in ordinary inflammatory 
 edema. L'lcerations in this region are rare unless the direct extension 
 of ulceration above the cord. The tracliea is but seldom involved com- 
 pared to the deeper structures, but we may ha\e in the trachea, the pale 
 swelling of the earlv stage of a perichondritis, the ulceration following 
 the breaking down of such a chondritis and all the phenomena following 
 the mixed infections. These same conditions may exist in the bronchi. 
 In a number of instances the author has seen a cheesy deposit filling the 
 entire luiuen (jf the bronchus which was occluded by cheesy pus anil 
 debris of a peribronchial gland which had eroded through. The mucosa 
 of tuberculosis, as a rule, is pale and ibi- pallor is ;iccentuate<l by the
 
 486 BRONCHOSCOPY IN DISEASES OF TRACHEA AND BRONCHI. 
 
 rather bluish streak of vessels where these are visible, as they sometimes 
 are. Erosion from peri-bronchial or peri-tracheal lymph masses may 
 be surrounded by granulation tissue of pale color or occasionally reddish 
 and sometimes streaked with blood. A most common picture in tubercu- 
 losis is a broadening of the carina, which may be so marked as to ob- 
 literate the carina and to bulge inward, producing deformed lumina in 
 both bronchi. Sometimes the himina are crescentic, the concavity of 
 the crescent being internal, that is, toward the median line. Absence 
 of the normal, anterior and downward movement of the carina on 
 deep inspiration is almost pathognomonic of a mass at the bifurcation, 
 and such a mass is usuallv tuberculous, though it mav be malignant, and, 
 rarely, luetic. The author had thought that, considering the frequency 
 of involvement of the upper lobe bronchus, pus should be found 
 draining from this bronchus as a rather frequent occurrence : but he has 
 rarely, in a case of tuberculosis, seen any secretion coming from the 
 upper lobe bronchus. Possibly the explanation may be that drainage by 
 cough and gravity had already removed secretion from the upper lobe, 
 or it may be that further observation may prove this experience excep- 
 tional. The onl\' lesion visible in a tulierculous case may be cicatrices 
 from healed processes. The author has seen one case of adventitious 
 dk'crticuiiim in the left bronchus immediately below the bifurcation. 
 The mucosa seemed quite cicatricial and it seemed probable that there 
 had been a sujjpurative process associated with glands in the mediastium 
 at the bifurcation. There was no active tuberculous lesion at the time, 
 but a radiograph by George W. Grier showed a mass of glands at the 
 bifurcation and calcareous glands in other locations. Tuberculosis may 
 almost entirely destroy the lungs of children without objective signs. In 
 one such case seen with Dr. Baldwin the left bronchus was occluded 
 with cheesy material and autopsy showed extensive tuberculosis of both 
 lungs. Yet the patient, a fourleen-months-old infant with thymic tracheal 
 compression had never been ill, nor had any rise of temperature ever 
 been noted. 
 
 Hemoptysis. Endoscopy may afford the only means of locating 
 and diagnosticating the source of hemoptysis. Manifestlv endoscopy 
 is not indicated in the hemorrhages of manifest, advanced pulmonary 
 tuberculosis. Rut in the not inconsiderable number of cases in which per- 
 sistent spitting of blood occurs in the absence of any objective signs of 
 tuberculosis and there is serious doubt as to the source of hemorrhage, 
 the doubt may be settled definitely by bronchoscopy. If the blood comes 
 from the air passages, it will be noted that there is an iiUerarytenoid 
 blood stream brought by the cilia up along the posterior wall of trachea 
 ruid out over the iiUerarytenoid space, like the pouring of a narrow
 
 HRONCHOSCOPY IN DISEASES OE TRACHEA AND BRONCHI. 
 
 487 
 
 stream of water out of the pitcher mouth, giving a curiously appropriate 
 justification for the naming of the arytenoid. This stream can be fol- 
 lowed to its source witli the bronchoscope. In a number of the au- 
 thor's cases (Bib. '2-i'^) the source of the blood has been a tuberculous 
 lesion. In other cases malignanc\- has been found. \ arix of the trachea 
 was the source in one of Ephraim's cases. Aneurysm has been found 
 endoscopically in a number of cases of hemoptysis. The author has 
 found a luetic lesion in three such cases. 
 
 C 1) 
 
 Fig. 409. — Endoscopic views of the bronchi in pneumothorax in a girl of nine- 
 teen years. A, left main bronchus. B, same just above the giving off of the 
 upper lobe bronchus. C, inferior lobe (stem) bronchus. D, orifices of inferior 
 lobe branch bronchi. 
 
 Fncitmothorax. The author has had three opportunities of exam- 
 ining the bronchi in jineumothorax. The endoscopic images in one case 
 are represented by the autiior's drawings reproduced in Fig. 40!). The 
 author can easily understand how such lumina might be produced with 
 the excejjtion of C (Fig. lO'.M, which .seems to him unexi)lainable, unless 
 it was due to absence of cartilage at that point. In the second case a simi- 
 lar concentric diminution of lumen was noted in another location, name- 
 ly the right inferior lobe bronchus. In the third case no such lumen could 
 be found.
 
 488 BKOXCHOSCOPY ]X DISKASKS 01^ TRACIIKA AND BRONCHI. 
 
 The mucosa in all was dark pink, but not cyanotic, in color. The 
 rings did not show. The main bronchus was collapsed from a point a 
 little below the bifurcation. 
 
 Angioneurotic edema. The author has not been so fortunate as to 
 observe a case of angioneurotic edema in the trachea, but it has been seen 
 endoscopically by Halstead and others. In Halstead's case the edema of 
 the bronchial wall produced bronchial dyspnea in a girl of fifteen years. 
 The endoscopic picture was a pale, evenly swollen mucosa producing 
 stenosis.
 
 CHAPTER XXX. 
 
 Diseases of the Esophagus. 
 
 I'rior lo llic ilcxelnpnicnt of esopliagoscopy, diseases of the esophagu-: 
 could be studied only autoptically, little was known and local treatment 
 was ineftective and very dangerous. It is no more justifiable to treat an 
 eso])hagus, or to ignore esophageal symptoms, without an esophagoscopy, 
 than it is to treat a i)atient with uterine symptoms without local examina- 
 tion. I'ntil recently the esophagus was being treated like the uterus was 
 in the author's student days, w-hen the family physician regarded local 
 uterine examination as a fussv ])reter.sion bordering on quackery. 
 
 The classification of esophageal diseases into stenotic and non- 
 stenotic is purely arbitrary, since all diseases of the esophagus may develop 
 stenosis, and stenotic diseases are usuallv not stenotic in their earlier 
 stages. Paralysis, while not stenotic in the sense of a constriction, is 
 clinically a stenosis l)ecause the patient cannot swallow even liijuids. 
 Nevertheless the terms "stenotic" and "non-stcnotic" arc conxciricnt. and 
 with the foregoing limitations on their meaning they will be herein used. 
 
 Diagnosis. The deductive methods of pre-esophagoscopic days, be- 
 ing inconclusive and more often wrong than right, are now entirely super- 
 sedcfl. Diagnoses are now made esop'iag(jscopically with all the certainty 
 of direct inspection su])plemented by bioi)sy when needed. 
 
 Radiography and fliioruscohy in diagnosis of esophageal diseases are 
 of the utmost importance and the roentgenologist and the esoi)hagosco- 
 pist are working together, each supplementing the other in many ways, as 
 mentioned imder the various diseases. Radiography and fluoroscopy 
 during the swallowing of an emulsion of some substance opaque to the 
 ray are of the utmos importance in the study of diseases of the esophagus 
 and the esophagoscope in no way lessens the necessitv of careful radio- 
 gra]>liy and rtuoroscoi)y which should be i)reliniinaries to e\ery eso- 
 phagosco]jy. They should go hand in hand. 
 
 Indications for esopliagoscopy in disease. .Any almcirnial sensation, 
 referable to the region or to the functions of the cso]ihagns, noticed by
 
 490 DISEASES OF THE ESOPHAGUS. 
 
 the ])atient calls for immediate esophagoscopy. Only in this way can we 
 hope to discover diverticula, esophagitis, lues, esophagismus, cardiospasm, 
 superficial ulcer, and other curable lesions in time to cure. Any sensation 
 such as "a lump rising in the throat," the so-called "globus hystericus.'" 
 calls for esophagoscopy, for the reasons given under "Spasmodic Sten- 
 osis.'' In the absence of any symptoms whatever, it is advisable to make 
 an exploratory esophagoscopy in cases of tracheal or high bronchial or 
 peri-bronchial mediastinal disease for the possibilities of information as 
 to periesophageal diseases. In the absence of any esophageal or tracheo- 
 bronchial evidence of disease, esophagoscopy is indicated in any case of 
 unexplained mediastinal radiographic shadow. The symptoms of eso- 
 phageal disease are so often stomachal in character that any obscure 
 stomach case requires esophagoscopy, and there is the added incentive 
 that the left two-thirds of the stomach can be examined at the same time 
 with the same instrument and with no more difficulty, in any case with- 
 out esophageal stenosis. The pyloric third of the stomach can be 
 examined in only a few cases. The most common form of confusion be- 
 tween gastric and esophageal diseases is for a patient to comi)lain of vom- 
 iting when reallv he regurgitates. Esophageal spasm is often caused by 
 organic or functional disease of the stomach. The gastroenterologist and 
 the endoscopist are working together with mutual benefit. 
 
 Contraindications to esophagoscopy are in some instances depend- 
 ent upon lack of skill on the part of the esophagoscopist. The trained 
 and skillful may examine any case of general or local disease with rela- 
 tively little risk, while in the hands of the rough, the careless or the un- 
 trained, the esopliagoscope is a dangerous and frequently fatal instrument. 
 The dangers are in inverse ratio to the skill, and are multiplied by the ex- 
 istence of wall-weakening esophageal disease. While the author would 
 not hesitate to advise esophagoscopy in a patient with aneurysm or very 
 hard arteries, or in one with extensive esophageal varicosities, advanced 
 organic disease, or extensive acute necrotic or corrosive esophagitis, if 
 there were very urgent necessity for it ; yet, esophagoscopy can be indi- 
 cated in such a case only by very urgent conditions, such as the lodgment 
 of a foreign body. If there is anything to be gained by it, a careful esoph- 
 agoscopy may be undertaken by the trained hand and eye which will 
 stop the procedure when an abnormal tissue which must not be passed or 
 even touched is encountered. In acute esophagitis fr(jm the swallowing of 
 corrosives it is better to defer the esophagoscopy until sloughing has 
 ceased and inflammatory infiltration has bulwarked the weak places. 
 Either extreme of age is no contraindication to esophagoscopy. The au- 
 thor has esophagoscoped a number of new-born infants, consequently 
 cannot agree with his distinguished colleague, Guisez, that "esophagoscopy 
 is inai)plicable at this age."
 
 DISEASI'S OF THK KSOPIIACUS. 491. 
 
 U'att-y hunger is one of the most urgent contraindications to esoph- 
 agoscopy. This condition, which makes the patient a very bad surgical 
 subject, does not seem to be recognized by the profession. 
 
 Patients that have been able to get but little liquid down for a 
 number of days, frequently come to the endoscopist and it is the au- 
 thor's custom always to have a surgeon in readiness on arrival of the 
 patient to iiave a gastrostomy done immediately, should the patient prove 
 to he in a serious state of water hunger. In the less severe cases water 
 is introduced into the circulation by hypodermoclysis and enteroclysis 
 simultaneously, and in the cases on which gastrostomy is done these meas- 
 ures are carried out while the operation is being done. There are few 
 conditions other than spasmodic stenosis and foreign bod)- occlusion that 
 are so quickly relievable that gastrostomy will not be needed anyway, and 
 it is better to do the gastrostomy first and make the diagnosis afterward. 
 Some ])atients are so far gone when they arrive that they die in spite ot 
 [)rompt enteroclysis. hypodermoclysis and gastrostomy. It seems that 
 when they get beyond a certain point they are hopeless. This point is 
 reached in from three to six days, dependent upon the weather and upon 
 whether the patient had or did not have an abundant supply of fluids 
 prior to the com])lcte occlusion. Of course the time in which death may 
 occur from water starvation may be prolonged by rectal feeding. 
 
 Gastrostomy, as indicated above, should always be done in stenotic 
 diseases of the esophagus before the patient begins to suffer for either 
 food or water. Like tracheotomy it should be done early rather than 
 late. If done early, gastrostomy is attended witli a mortality of less than 
 one per cent, and as a life saving measure, it is of the utmost importance. 
 Gastrostomy is advisable in some instances, even when the patient can 
 swallow liquids, for the purpose of putting the esophagus at rest. True, 
 secretions will still drain down the esophagus but these do not stagnate 
 and macerate like food, even ii(|iiid food, does. 
 
 Rectal feeding. The water from nutrient cnemeta is absorbed rather 
 readily and, if carefully watched and faithfully and i)ersistently carried 
 out in small continuous dosage, will supply the system with fluids and 
 postiione, for a long time, death liy water starvation; but fur nutrient 
 pm-iioses rectal alimentation is dangerously incflicieiit. 
 
 Indirect e.V(iiiii)ialion af esx/^hiKieal eases. The larynx and pharynx 
 should be examined in all cases of suspected esoi)hageal disease. I^aryn- 
 geal disease involving the e[)iglottis, arye])iglottic folds, arytenoids or 
 yiarty-wall may be tluis found to account for all the symptoms and may, 
 in some cases, negative esophagoscopy. It is characteristic of anv form 
 of esopli.'.geal stenosis, if of a severe type, that both jiyrifcn'm sinuses 
 will be full of fluid in the erect posture of the patient. The cause of this
 
 4d2 disi:asi:s of the esophagus. 
 
 is that the fluids which normally are continually flowing away through 
 the esophagus, are unable to escape downward in stenotic cases, and thus 
 the pyriform sinuses fill for want of normal drainage. This condition is 
 known as the author's sign and is diagnostic of a high degree of eso- 
 phageal stenosis. Levy has called the author's attention to an exception 
 to the ])athognomv of this sign in advanced cases of laryngeal tuberculosis 
 in which the pain of swallowing is so great that swallowing is deferred 
 as long as possible. Possibly also there is, in some such cases, an eso- 
 phageal stenosis due to spasm of the cricopharyngeus, a reflex from the 
 painful laryngeal lesion. 
 
 Technic of esopliagoscopy for diseases. The introduction of the 
 esophagoscope has been fully considered. The esophagoscope should in 
 every case be passed by sight. Danger of perforation and of overriding 
 the disease by mandrin introduction renders the introduction by sight 
 the only method worthy of consideration. Xo anesthesia, general or local, 
 is needed, as explained in Chapter l\', though local anesthesia of the 
 laryngopharynx is unobjectionable in adults if desired. The position 
 should, preferably, be recumbent as explained in Chapter \T. For the 
 diagnosis and treatment of diseases of the upper end of the esophagus, 
 the esophageal speculum. Fig. 'i^ . is. in the author's experience, the most 
 serviceable instrument. It can be used, if desired, in the recumbent or 
 sitting position of the patient as described in Chapter X. 
 
 .\NOMALIES OF THE ESOPHAGUS. 
 
 Congenital malformations of the esophagus may be divided into 
 imperforation, stenosis, and esophago-tracheal fistula. 
 
 Imperforate esophagus. So far, the author has not had an oppor- 
 tunity of passing the esophagoscope on a case of imperforate esophagus, 
 but he has passed the esophagoscope on (|uite a number of infants, the 
 youngest being two days old. It was suspected in this latter case that an 
 imperforate esophagus existed, but on esophagoscop)', the lumen of the 
 esophagus was found perfectly normal all the way to the stomach. The 
 disappearance, after the passing of the esophagoscope, of the difticulty 
 in swallowing would seem to indicate spasmodic origin. When examined 
 ff)ur months later by Dr. .Manchester the child was still swallowing per- 
 fectly. In view of this case, and of many others on children from a few 
 days to a few months of age, the author must disagree with Guisez in the 
 statment that "esophagoscopy is inapplicable at this age." An esopli- 
 agoscopy can be done in the new-born with perfect safety, provided a 
 very small tube be used, and, provided, of course, it be with a proper 
 degree of care. The most usual site of the occlusion is in the mediastinal 
 esophagus, the upper esophageal segment ending in a lilind pouch, usual-
 
 DISEASKS OF Tin; ESOPHAGUS. 493 
 
 iy more or less ililatcd. A fistula may exist between the lower segments 
 of the anomalous esophagus, the upper segment being injierforate. 
 (Guthrie and Edington, Bib. 135.) 
 
 Congenital csopluu/otraclical tisliilac are the most frequent anomaly. 
 They are due to embryonic developmental errors. So far, no cases of 
 esophagoscopic examination of congenital tracheo-esophageal fistulae 
 have been reported, but as the procedure is safe and simple, doubtless ob- 
 servations will be made. In the case of a nursling of six months of age 
 which fell under the author's care, a tracheo-esophageal fistula, due to 
 ulceration, would never have been suspected had not the parent suspected 
 foreign body, which was found on radiographic examination and was re- 
 moved by the author. There was no suspicion on the part of the parents, 
 nor of the physicians who examined the patient prior to Dr. Sullivan, of 
 any ditticulty in swallowing. The parents were concerned solely with. 
 their observation that "the baby coughed until it vomited'' and the child 
 undoubtedly had a broncho-pneumonia. In a fistula in the new-born, 
 there might be nothing to lead one to suspect difticulty in swallowing, and 
 doubtless, cases of congenital fistula have been buried under an erroneous 
 diagnosis. Some of the rare cases of tracheo-esophageal fistula without 
 atresia probably live for some time, because some of the food escapes 
 l)ast the fistula into the stomach. 
 
 Cougciiitii! stricture uf the esophagus may be more fre(|uent than 
 heretofore sui)pf)sed. Cases are encountered bv the esophagoscopist 
 where the |)atient has had more or less difficulty in swallowing which is 
 often described as "not swallowing as well as other peo])le." \'ery often 
 these cases have more or less frecpient intervals of exacerl)atic)n of their 
 sym[)toms when the swallowing difficulty becomes quite troublesome. On 
 esophagoscopy, such cases show a moderate stenosis which does not seem 
 to be cicatricial, and yet is, ne\ ertheless, an organic stenosis not due to 
 compression. There is a strong sus])icion that such cases may be in 
 some instances due to the swallowing of caustics in cliil(lhoo<l, but in the 
 absence of any such history, the parents being intelligent, it seems justi- 
 fiable, to class them as congenital. A very interesting suggestion is made 
 by .X. Brown Kelly (Bib. 30;i) ; namely, that stenosis of the esophagus 
 l)n)ducing no symptoms until early adult life may nevertheless be con- 
 genital, since, as demonstrated by Mavlard, congenital narrowing of the 
 jjylorus rarely manifests itself before early adult life. The suggestion of 
 ISrown Kelly would explain those rare cases, of which every esopliagos- 
 co])ist of experience has seen a few in which there is an obvious stenosis 
 of the esophagus, non-cicatricial and certainly non-spastic, first produc- 
 ing .symptoms after adolescence. iMutlur data are to be hoped for.
 
 491 DISEASICS OF THK liSOPHAGUS. 
 
 IVebs in the upper third of the esophagus have been observed. The 
 author has found that in any case where the presence of a web is sus- 
 pected, the best method of determination is to put the esophagus on the 
 stretch with a very large esopliagoscope, or, preferably, with the eso- 
 phageal speculum shown in Fig. "21. Retraction of the anterior wall of 
 the esophagus will stretch the web quite thin, and it is ver}- easy to pass 
 an alligator forceps through the narrowing and then withdraw the for- 
 ceps which are spread. This will dilata the constricted lumen due to the 
 web, and if carefully done, the procedure is entirely harmless. It is wise 
 to pass the speculum every alternate day until healing is complete. 
 Smaller webs with larger esophageal lumen may be stretched by passing 
 the esophageal speculum without the use of any other dilating instrument. 
 Unlike cicatricial strictures, the web has very little tendency to vicious 
 cicatrization and reproduction of the stenosis. 
 
 Treatment of esophageal anomalies. Unfortunatelv there is not often 
 an opportunity for treatment. Gastrostomy is indicated in imperforate 
 cases. Esophagoscopy has nothing remedial to ofifer except in cases of 
 stricture and webs. Strictures can be dilated, but even more care should 
 be exercised here than in cicatricial strictures. The few probably congen- 
 ital cases the author has seen yielded more promptly than cicatricial sten- 
 oses of the same size of lumen and had less tendency to contract. In none 
 of the cases was the full size of the esophageal lumen restored, but the 
 patients remained free from dysphagia. \\'ebs are very successfully dealt 
 with as already mentioned. 
 
 Rupture and trauma of tlie esophagus may be spontaneous or may 
 result from the trauma of an instrument or of a foreign body, or of both 
 combined, as was frequently the case in the old days of blind attempts 
 at pushing a foreign body downwards. MacReynolds reports a case of 
 spontaneotts rupture of the esophagus following extensive ulceration of 
 the esophageal wall. The patient had been operated upon for an uncom- 
 plicated mastoiditis. The death, some days after operation, was found at 
 post mortem to be due to ])rofuse hemorrhage following rupture, which 
 was in the lower third. Xo unusual strain had been put upon the esoph- 
 agus and no solid food had been taken for a week. Rupture of the 
 esophagus is usually attended with mediastinal emphysema, profound 
 shock, a weak rapid pulse, restlessness, fever and rapid sinking. If the 
 pleura has been torn, as is frequently the case, the symptoms and physical 
 signs of ]>neumothorax are added. In such cases tapping of the pleural 
 cavity will usually obtain a small amount of fluid with fecal odor. Lesser 
 degrees of trauma not perforating all the layers of the esophageal wall, 
 may show slight symptoms of esophagitis (q. v.). The early endoscopic 
 appearances of esophageal trauma are those of a bleeding laceration of
 
 DISEASES OF THE ESOPHAGUS. 495 
 
 the mucosa. Later int1ammat(jr\' and ulcerative a]>i>earaiices ( q. v.) arc 
 manifest. 
 
 The treatment of trauma without perforation is the same as for 
 acute esophagitis {<.\. v.). The traumatism due to the foreign body itself 
 is almost invariably e.xceedinglv slight and does not penetrate deeply and 
 heals promptly. Jjlind methods of removal, however, are often attended 
 with serious and fatal traumatism. The food in any case should be sterile 
 liquids only, and all water should be sterilized and served sterilly. Rup- 
 ture of the esophagus demands immediate gastrostomy (under local an- 
 esthesia ) to nourish the patient, to supply him with fluid, and to put the 
 esophagus at rest. If the pleura has been ruptured immediate thoracot- 
 omy, with insertion of a drain at the most favorable point of drainage, 
 may save life, which without this procedure, is hopeless. Stimulation, 
 hot-water bags, elevation of the foot of the bed, atropine and other shock 
 combating methods are indicated. The patient's head should be low 
 and the mouth turned toward the pillow to lessen the drainage of se- 
 cretions into the esophagus. 
 
 INFLAMMATION .\ND UECEKATION OF THE E.SOPHAGUS. 
 
 Acute esophagitis is usually of traumatic or cauterant origin. If 
 severe or extensive, all the symptoms described under "Rupture of the 
 Esopliagus" may be present. The endoscopic appearances are unmistak- 
 able to anyone familiar with the appearance of nuicosal inflammations. 
 The pale, bluish pink color of the normal mucosa is replaced by a deep 
 red veK'ety swollen ajjpearance in which individual vessels are invisible. 
 After exudation of serum into the tissues, the color mav be paler and 
 in some instances a typical edema may be seen. This may diminish the 
 lumen tem])orarily. If the inflammation is due to corrosives, a grayish 
 exudate may be visible early, sloughs later. 
 
 i'lceration of the csopha(jiis. In the main, the observations of the 
 author in his earlier volume ( l!ib. '^ii!i ) have been fully borne out by 
 further experience. W'liile ulceration of the eso])hagus cannot be said to 
 be a common disease, yet those who examine the esophagus constantly, 
 meet with occasional cases. Superficial erosions are by no means un- 
 common, and the condition of inflammation, at times associated with 
 erosion and even with ulceration, that accom])anies the stagnation of food, 
 is a very important part of the pathology of esophageal stricture. Lender 
 the head of spastic stenoses, the author has described the condition as con- 
 stituting a "vicious circle" wherein spastic stenoses, w-hether due primar- 
 ily to esophagitis or other local lesion or not, excite, or at least perpet- 
 uate an eso])hagitis, which, in turn, is a factor in the production of the 
 spastic stenosis. The more constant the spastic condition, necessarily the
 
 496 DISEASES OF THE ESOPHAGUS. 
 
 greater the degree of esophagitis. The author has met with a number of 
 cases of manifestly cicatricial stenosis, which, from the history, seem to 
 have resulted from such a condition. There had been no history of swal- 
 lowing any corrosives in childhood, and the esophageal trouble came on 
 comparatively late in life so that any accidental cause for the production 
 of a cicatricial stricture would necessarily have been remembered by the 
 patient. One case of ulceration of the esophagus observed by the author 
 deserves special mention : 
 
 A girl, aged two xears. was brought to the author by Dr. L. C. Man- 
 chester for ditiiculty in swallowing which had come on during an attack 
 of aphthous stomatitis. The child had been listless and had refused to eat. 
 Temperature 102- F. (39° C). It had been thought that it refused to 
 swallow simply because of the pain in the mouth, but after 24 hours with- 
 out food or water, the child made strenuous efforts to swallow but the milk 
 came back promptly. Upon examination with the child's esophageal 
 speculum. Fig. 21, the cricopharyngeal constriction was seen to be the site 
 of three small ulcerations. The T mm. esophagoscope was introduced be- 
 low these ulcerations, and it was discovered that in the middle third of 
 the esophagus there were two distinct ulcers and one elongated ulceration 
 which had the appearance of two ulcers having coalesced. Just below 
 this were two small vesicles, each surrounded by a red areola. A soft 
 rubber tube was introduced and the child fed. It was given a few drops 
 of an alum, sage and honey mi.xture, and in about ten days was entirely 
 well of the lesions in the mouth and the swallowing was normal. A sec- 
 ond esophagoscopy thirty days after the first, showed a normal esophagus. 
 
 Remarks. It was quite evident that the difficulty in swallowing was 
 entirely spasmodic as no stenosis was found and the esophagoscope met 
 with no obstruction in passing all the way to the stomach. 
 
 Ulceration may follow trauma of a foreign body, an instrument or a 
 corrosion, and, of cou.rse, is part of nature's method of repair. Sloughs 
 may be present, and exudates and exfoliation may modify the endoscopic 
 picture. 
 
 Differential diagnosis of nicer of the esophagus. To recognize the 
 presence of an ulcer esophagoscopically is not difficult if it be not covered 
 with macerated epithelial debris, bismuth, food or secretion, but to de- 
 termine that it is a simple ulcer, requires the exclusion of lues, tuber- 
 culosis, epithelioma, endothelioma, sarcoma, and actinomycosis. Simple 
 ulcer of the esophagus is usually associated with a stenosis, spastic or or- 
 ganic. In the absence of a stenosis, we are usually justified in excluding 
 simple ulcer. This is not absolute (see case above cited), but it arouses 
 a very strong suspicion that the ulcer is either malignant or luetic. The 
 characteristics of the luetic ulcer are the highly inflammatory state of the
 
 DISEASES CV THE ESOPHAGUS. 497 
 
 surrounding mucosa, the thickened elevated edges usually free from gran- 
 ulation tissue, with a somewhat pasty center and not bleeding readily 
 when sponged, though the surrounding mucosa gives one the impression 
 of being intensely vascular. The tuberculous ulcer, if primary in the 
 esophagus, is very superficial and seems to partake more of the char- 
 acter of an erosion than of ulceration. The mucosa is pale and gives one 
 the impression of anemia. It is usually free from granulation tissue, but 
 there mav be small granular elevations at different points, usually rather 
 scattered. There may be slight cicatrices. If, however, the tuberculosis is 
 an extensirjn by continuity from periesophageal tuberculous glands, and 
 especially if there is a fistulous communication with a bronchus, we may 
 have quite a cauliflower growth of granulations, though usually they are 
 quite pale. In the cases in which a tuberculous process has invaded the 
 cso])hagus from either a lung lesion, or a mediastinal adenopathy, there is 
 usually such a manifest tuberculous syndrome that the diagnosis can be 
 made therefrom. The tuberculin test, reverse tuberculin test, guinea pig 
 injection with emulsion of tissue, with the histologic examination of tis- 
 sue for the bacilli and for the morphologv of tuberculosis — all these taken 
 together are almost absolutely decisive; though the remote possibility ol 
 a mixed lesion of tuberculosis with lues or malignancy must be borne in 
 mind. The ulcer of sarcoma does not differ materially from the ulcer 
 of carcinoma. The carcinomatous ulcer is usually characterized by the 
 very vascular bright red zone, raised edges, granulation tissue that bleeds 
 freely on the slightest touch, and above all, it is almost invariably sit- 
 uated on an infiltrated base, which communicates a feeling of hardness to 
 the pressure of sponges or of the esophagoscopic tube itself. Another 
 characteristic sometimes seen in carcinoma is the pointed projections 
 springing somewhat like granulation tissue from the ulcer or its neigh- 
 borhood. A scar mav be from the healing of an ulcer of simple or 
 specific character, or, on the other hand, it may be a cancerous process 
 develo])ing on the site of a scar, so that the presence of scar tissue does 
 not absolutely negative malignancy. As a rule, however, we do 
 not see a scar in cases of cancer of the esophagus. In determining in- 
 filtration, we must be on our guard not to be misled by the sensation com- 
 municated in some cases by the ridge ])roduccil by the lett bronchus 
 where it crosses the esophagus. In some cases of esophageal disease with 
 dilatation, cs|)eciall\' if the stenosis is not far below the bronchus, the 
 ridge protruded by the crossing of the bronchus is ai'l to lie inominent 
 and feels quite resistant to the pressure of the tube. In some instances 
 it is possible to make an accurate diagnosis of a simple ulcer by exclusion 
 through esophagoscopic appearances alone. Usually, however, the aid 
 of the l.'iboratorv nuist be invoked, chicflv because lesions occur more or
 
 408 DISEASES OF THE ESOPHAGUS. 
 
 less mixed in character, owing to the fact that all ulcerations of the esoph- 
 agus are associated with mixed infections. The resultant infective in- 
 flammations give a uniformity in character that interferes seriously with 
 differentiation, because infecti\e inflammation is apt to produce the same 
 esojihagoscopic appearance regardless of the lesion which caused the 
 primary solution of continuity. The foregoing remarks apply only to 
 the ulcerated lesions of the diseases mentioned. The differentiation of 
 non-ulceratetl lesions is elsewhere herein considered. In any case of ul- 
 ceration of the esophagus unassociated with stasis, we are justified in 
 pushing the therapeutic test with potassium iodide and mercurial in- 
 unctions. We are also justified in sponging the surface of the ulcer with 
 a gauze sponge ; but to obtain a specimen, it is seldom justifiable to scrape 
 the ulcer, unless it is on a verv much infiltrated base. If the edges are 
 thin and flat, the taking of a specimen of tissue involves some risk. If, 
 however, the ulceration has a thickened elevated edge, this edge may be 
 nipped off with the tissue forceps. Fig. 35. The histologic examination 
 of the tissue and a bacterial examination of the secretions wiped from the 
 face of the ulcer, should give accurate information. If the laboratory 
 report is uncertain, we are justified in repeating the removal of specimens 
 of tissue and secretion a number of times. A positive W'assermann, or 
 luetin, or a positive luetic history only makes the therapeutic test all the 
 more strongly indicated. That the man has had lues does not necessarily 
 mean that the ulcer in question is luetic, for a luetic man may have a 
 malignant growth or be subject to tuberculosis ; in fact it is a serious 
 question whether or not lues i)redisposes to these conditions. Spirochetal 
 findings in a si)ecimen of tissue is decisive, but failure to find is diag- 
 nostically valueless. 
 
 Treatment of acute and subacute inflanunatioii and ulceration of 
 esophagus. As a rule, a simple ulcer, associated as it almost invariably 
 is with more or less stenosis and stasis, usually yields to the local ap- 
 plication of argyrol, with rest of the esophagus. The best way to obtain 
 this rest is to do a gastrostomy for feeding so that nothing but secre- 
 tions will go through the mouth. The teeth and mouth, of course, 
 should be kept scrupulously clean. If the ulceration heals by these means 
 alone, without any other treatment whatsoever, we may be justified in 
 concluding that the ulceration was of simple character. 
 
 In all forms of esophagitis and in the ulcerations consequent upon 
 traumatism, such as that of foreign bodies, the usefulness of bis- 
 muth subnitrate has been ami)ly demonstrated by the author. It is given 
 dry on the tongue and swallowed preferably without li(|uid in order bet- 
 ter to adhere to ulcerated surfaces. That il does adhere, the author has 
 noted in a number of cases in which the bismuth had been given ther-
 
 DISEASES OF THE ESOPHAGUS. 499 
 
 apeutically, and also in oases in wliich it had been used in order to (il)tain 
 a ray picture in cases of esophageal stenosis. The comliination with a 
 little calomel given from time to time is excellent, llismuth has quite a 
 good deal of antiseptic action, hut whether this be the explanation or 
 not, empirically the author has had abundant evidence that this treat- 
 ment for inflammation and ulceration of the esophagus is curative. 
 Argyrol in 'i'> per cent solution locally ai)plie(l esophagoscopically is also 
 useful in cases of ulceration, and especially those attended with funga- 
 tions. In three cases wheve external operations through the neck had in- 
 volved the esophagus, dysphagia was found by the author to be due to an 
 unhealed wound in the esophagus, and in all three cases, apjilications of 
 argyrol resulted in healing. 
 
 Chronic cso/^liag'tis. The appearances of chronic esophagitis will be 
 dealt with in connection with diffuse dilatation and spasmodic stenosis. 
 
 Treatment of chronic csofthai/ifis. 'I'he best treatment for chronic 
 esophagitis is the correction of stenoses, organic or spastic, which exist 
 below. ]irciclucing stasis of ff)od. If the stenosis is not completely curable, 
 local remedies are of great aid in limiting the degree of inflammation. 
 Jlisniuth subnitrate is the best remedy. Calomel may be given also occa- 
 sionally, both of these being given dry on the tongue. The best local en- 
 doscopic a];plicatinn is argyrol in l."i per cent solution. 
 
 CilMI'Ki:sSI0N STENOSIS OE THE Esorii.vc.us. 
 
 Compression stenosis may be the result of any periesophageal disease 
 or anomaly. The most fre(|Ueiit lesions are thyroid enlargement, cervical 
 or thf)racic, malignancv. aneurysm, auricular and aortic enlargement, or 
 calcification, Ixmphatic infiltration, lordosis. Thoracic compressions are 
 usually from mediastinal lesions, though the author saw one case of com- 
 pression b\' a cancerous lung that had not \et invoKed the mediastinum. 
 In an<jther case a walled-off abscess of the u[)per lobe of the right lung 
 and pleura caused the com])ression without mediastinal involvement. In 
 two cases of the author comjiression of the esophagus was due to ]ires- 
 stire of a hy])ertrophic(l heart. Bassler has reported a case due to hyper- 
 trophy of the auricle. Stenoses in the lower part of the thorax are \ery 
 rarely comjtressive. 'i'he author has seen one such case associated with a 
 pleural fistula \\hich had been discharging for years subsequent to sur- 
 gical evacuation of an empyema so that the exact nature of the compres- 
 sive tissue could not be made out. Collier rejwrts a case of compressive 
 stenosis from cancer of the liver and Cottstcin one from the pressure of a 
 calcareous area in the pleura. 
 
 Differential dia(/>iosis of c<nnf'rcssi7r stenoses of the esofhoj/iis. 
 The existence of a stenosis is often indicated by the .uuhor's sign of se-
 
 500 DISEASES OE THE ESOPEIAGUS. 
 
 cretion-fiUed pvriform sinuses. Compression stenosis covered with nor- 
 mal mucosa, can be readily differentiated in most cases from disease of 
 the wall of the esophagus: but the nature of the compressive lesion and 
 its extent outward from the esophagus will usually require the aid of the 
 roentgenologist or fiuoroscopist. Compression stenosis is manifested 
 usually by a slit-like crevice which occupies the place of the lumen and 
 which does not open up readily before the advancing tube. The slit may 
 be curved, and its long axis is almost always at right angles to the com- 
 pressive mass if the esophageal wall be uninvolved. The normal radial 
 creases separating the folds are diminished to two, one at each end of the 
 crescentic slit-like lumen. The covering mucosa may be normal or show- 
 signs of chronic inflammation from stasis. If the esophageal wall is un- 
 involved the esophagus is mo\alile laterally with the tube-mouth and the 
 mucosa can be readily pushed up into folds. 
 
 Goitrous coinpression of the esophaaiis by a cervical goitre is readily 
 confirmed by palpation of the neck, but with a substernal goitre \erifica- 
 tion is not so easy. Corroboration is to be had from radiography. The 
 esophagus is not so often seriouslv compressed as is the trachea. 
 
 Aneurysmal couihrcssiou of the esophagus. Theoretically, one might 
 suppose that the endoscopic picture in an aneurysmal compression 
 stenosis of the esophagus must be expansile. As a matter of fact, how- 
 ever, in all of the cases that the author has observed, the pulsation seems 
 to be simply a transmitted pulsation of the aneurysmal sac acting simply 
 as a tumor might in transmitting the pulsation from the aorta itself. The 
 author has observed, in many instances, in abdominal esophagismus, a 
 very much more inarked pulsation with w-ider excursion in the absence 
 of any lesion, which coincides with the observation of Boyce that cases 
 of abdominal esophagismus are often associated with a \ery much en- 
 larged aorta. As pointed out by Sargnon (Bib. 491 j very slight degrees 
 of aneurysm are extremely difficult to detect either by physical signs or 
 by radiography and may even be overlooked at esophagoscopy unless the 
 most extreme caution is taken. It would lie easy to be misled into at- 
 tempting blind biniginage and doubtless this does happen with those who 
 are not familiar with the uses of the esophagoscope. In using the esoph- 
 agoscope on such cases it is necessary, as Sargnon points out, not to 
 go, below any sort of comjiression or narrowing until aneurysm has been 
 excluded by all available means including esophagoscopic stud\-. 
 
 Aortic compression of the esophac/us was alluded to above in writ- 
 ing of aneurysm. In one of the author's cases a compression stenosis 
 was noted at the level of the arch of the aorta. Radiography revealed 
 such a dense irregular shadow of the aortic wall as to render justifiable 
 the opinion that the aortic wall was to a greater or less extent calcified.
 
 DisEASKS oi- Tin; ksophagus. 501 
 
 The patient was a man (ill years of age. An examination of the hterature 
 revealed a number of cases, a most notable one by Anthony Bassler. A 
 number of observers have confirmed observations of Kovacs and Stoerk 
 in regard to the kinking of the esophagus by enlargement of the left au- 
 ricle. The author has since observed in two cases very marked compres- 
 sions and deviations from this cause. In both cases there had been no 
 symptoms referable to the esophagus but a large mass of meat had lodged 
 and was removed esopliagoscopically. 
 
 Carcinomatous and sarcomatous coinf^rcssions of the csophai/iis are 
 characterized by their hardness when jialpated by the tube mouth or 
 probe. 
 
 Adenopathic compression of the csopha(/us. !Minor compressions 
 are often noted, and the diagnostic and prognostic value of the esophagos- 
 copically demonstrable lymph nodes at the sides of the esophagus has 
 been noted in connection with cancer of the larynx. A high degree of 
 stenosis may be due to a large mass of infiltrated glands in the medias- 
 tinum especially below the crossing of the left bronchus. Usually trach- 
 eal, bifurcational or bronchial stenosis may be found in the same case. 
 In any comjiressive stenosis of the mediastinal esophagus in an adult, 
 not clearly malignant nor tuljerculous, it is wise to give potassium iodid 
 and mercury, which must be pushed to a full therapeutic test without 
 stopping al the first sign of iodism. If this be done, an occasional cure 
 will result, of which the author has seen a number of instances. Lordosis 
 is a not infrec|uent cause of compression stenosis of the cervical esoph- 
 agus. The prominence of the posterior wall and the boay hardness 
 render identification easy. It is doubtful if scoliosis produces any com- 
 pression or deviation of the esopha.gus. Xo such cases have been re- 
 corded, to the writer's knowledge. The investigations of H'-^ker and 
 Kollicker render the occurrence doul)tful. 
 
 The frequency with wliich posticus laryngeal paralysis is associated 
 with compressive esophageal stenosis .should be borne in mind. 
 
 Treatment of compressive stenosis of the esophagus. Curative treat- 
 ment is necessarilv concerned witii c\ire of tiie compressive lesion and 
 hence is not within the province of endosco[)y. I'nless the diagnosis of 
 the nature of tlu- compressive lesion is certain it is well to give potassium 
 iodid and tnercur\ , as an occasional cure of a gummatous or adenopathic 
 luetic lesion in a sup|)0se(lly malignant or other case will occur. Palliative 
 treatment by esophageal intub:ition (q. v.) is indicated in all conditions 
 except aneurysm. This is quite feasible and satisfactory in many cases 
 in which the ordinary stomach tube cannot be passed. Castrostomy 
 should be done earlv when ncccssarv.
 
 502 DISEASES OF THE ESOPHAGUS. 
 
 DIEFlSE DILATATION OF THE ESOPHAGUS. 
 
 This is practically always stagnation ectasia. The adherents of tlie 
 atonic theory of diffuse dilatation are now few and there is little evi- 
 dence, clinical, anatomical, or physiological, to support their view. In 
 the author's experience, dilatation of the esophagus has been invariably 
 associated with either organic or spasmodic stricture, existing either at 
 the time of the observation or at some time prior thereto. In four cases 
 of dilatation discovered b}- the author during gastroscopy in [jatients with- 
 out esophageal symjitoms, there was a history indicating clearly a spas- 
 modic stenosis earlier in life. The action of the stricture in causing dif- 
 fuse dilatations, whether the stricture be spasmodic or organic, is prob- 
 ably largely due to deglutitory pressure of accumulated food. Though 
 gravitation does not much aid normal deglutition, it probably aids in in- 
 creasing a suprastenotic dilatation. It is not at all necessary that the food 
 should remain a long time in the esophagus. The esophagus seems to be 
 constituted on the basis of immediately emptying itself of whatever may 
 enter it from either above or below. In other words, it is intolerant of 
 the ])resence of anything excejit its own normal secretions and these must 
 be in very small amounts and continually draining away. Stagnation 
 even of secretions will produce not only dilatation, but esophagitis. If 
 a stricture is not very small and yet is sufficient to hokl back for a time 
 what has been swallowed, the esophagus acts as a reservoir of a large 
 funnel with a very small opening. When food is swallowed, the esoph- 
 agus fills and the contents trickle slowly through the opening. This 
 distension is sufficient to result in permanent dilatation, and strange to 
 say, such dilatation always remains once it has been established (Jesse 
 Mayer, Bib. 3!)!)), even though the stenosis which caused it has entirely 
 disappeared. It seems likely that the gases due to fermentation of the 
 stagnant food may increase the dilatative pressure beyond what w'ould 
 result from mere gravity, because we practically never see in cases of 
 organic stenosis the enormous degrees of dilatation seen in spastic 
 stenoses. Theoretically it would seem that there existed in cases of 
 hiatal and abdominal esophagismus a spasm also of the cricopharyngeus 
 and associated circular esophageal fibres, preventing ready escape of the 
 gases upward. As a matter of fact many of the patients observe a dis- 
 tress partially relieved at intervals by the escape of gas. That the re- 
 lief is not complete is probably due to the irritation from food and gases 
 still remaining in the dilated esophagus. A very large dilatation of the 
 thoracic esophagus indicates a spastic stenosis. Cicatricial stenoses do 
 not result in such large dilatations, possibly because of leakage shorten- 
 ing the duration of stasis. Malignant stenoses do not exist long enough 
 to cause very large dilatations, though small ones are common and their
 
 DISEASES OE THE ESOPHAGUS. 503 
 
 size is an indi-x of llu- liiiralioii of the growth; tliough the possibility of 
 malignancy develo])ing in a spastic case must be remembered. 
 
 Treatment of diffuse dilatation of the esophagus. The treatment of 
 diffuse dilatations that produce symptoms consists in dilating the hiatal 
 and abdominal esophagus, even in cases where spasm cannot be demon- 
 strated. This dilatation will relieve the patient of the symptoms and of 
 the stagnation of food, though the increased size of the esophagus after 
 dilatation w-ill never disappear. Treatment is, therefore, the same as if 
 hiatal or abdominal eso|)hagismus could be demonstrated. If chronic 
 csophagitis is present, as it usually is, the administration of bismuth sub- 
 nitrate with calomel occasionally, and possibly, in some cases, the local 
 csophagoscopic application of argvro' solution, ,'i per cent, are indicated.
 
 CHAPTER XXXI. 
 
 Diseases of the Esophagus. Continued. 
 
 SPASMODIC STENOSIS OF THE ESOPHAGUS. 
 
 The aiitlior's early urging of endoscopists to make a thorough study 
 of spasm has borne abundant fruit. Esophageal spasm in the earlv days 
 of endoscopy was considered one of the rarest conditions, while to-day it 
 as.sumes etiologically and pathologically, first place in importance. The 
 factor of spasm enters into nearly every condition of the esophagus with 
 which the endoscopist has to deal, even in foreign body cases where a 
 foreign body of very small size may excite sufficient spasm entirely to 
 occlude the esophagus, so that even liquids cannot be swallowed. In 
 speaking thus of the importance of spasm and its frequency, the author 
 does not allude to what the beginner in esophagoscopy is likely to en- 
 counter. Nearly every beginner thinks in every case in which he has 
 difficulty in introducing the esophagoscope past the cricoid, that the pa- 
 tient has a spasmodic stenosis. It is not until introduction has become 
 easy that the endoscopist is able to determine whether true spasm exists 
 or not, at the upper end of the esophagus. Of course, there is always 
 more or less of spasm of the cricopharyngeus in every case, unless the 
 patient be very profoundly anesthetized ; but this does not constitute true 
 pathologic esophageal spasm. Esophageal spasm might be classified into 
 spasms of the upper end and those of the lower end, for it is very rarely 
 that spasm exists in the middle third. The objection, however, to this is 
 that we cannot always dissociate high and low spasms, because they may 
 coexist or may alternate in the same case. A disease of the lower third 
 may cause spasm of the upper end of the esophagus and vice versa. For 
 this reason also, the symptoms and the sensations of the patient are not 
 to be relied upon. The patient may complain of inability to even start 
 food down, when upon esophagoscopy, we find that the lesion is located 
 at the cardia, in which case if we were to rely upon symptoms, we would 
 expect the food to be swallowed and then regurgitated after a longer or
 
 DISEASES OI- THE ESOPHAGUS. 505 
 
 shorter time. It is no woiuk-r, tiifii, that httlc progress was made in the 
 study of the diseases of the esophagus prior to recent general use of the 
 esophagoscope. Without underestimating the very valuable results to be 
 had from radiography, it must be said that only by esophagoscopy can 
 the exact nature of lesions be determined without grave risk of error, as 
 elsewhere mentioned. On the other hand radiography and fluoroscopy 
 render such excellent service that they are indispensable. Consequently 
 the esophagosco]>ist and the roentgenologist both must labor to obtain the 
 best results for the patient. The best illustration of this is the fact that 
 while the esophagoscoi)e can give all the certainty of actually seeing the 
 spasmodic closure and above all it alone can inform us of the mucosal 
 lesions: yet it cannot, as can fluoroscopy and radiography, inform us of 
 the physiologic functional patho!og\- during the act of deglutition. 
 
 Etiology of spasm of the esophagus. It is easy to luidcrstand why 
 the csophagtis should be es[)ecially prone to spasmodic disease. Its en- 
 tire functional activity is dependent upon reflex action. Each part of the 
 gullet, as the l)iiius of food reaches and dilates it, is stimulated to con- 
 tract, thus a peristaltic wa\e moves with the bolus of food as it is swal- 
 lowed, and while it is undoubted that the pneumogastric nerves are con- 
 cerned in the swallowing act, yet it is nevertheless true that the action is 
 excited reflexly, because only the very start of the swallowing motion is 
 voluntary. Once the start is made by the constrictors, the balance of the 
 movement is a reflex jieristalsis. Swallowing is impossible if both vagi 
 arc cut. The latter experiment would contraindicate the possibility of 
 paralysis or paresis being in some instances the cause of what is known 
 as "cardiospasm," especially as the division of these nerves causes con- 
 traction of the esophagus in the neighborhood of the cardiac orifice, as 
 though there were inhiliitory fibers supplied only to the region of the 
 cardia. The auliior, however, esophagoscopically has deriionstrated very 
 clearly, by the watching of a few cases where "cardiospasm," so called, 
 has been seen early but for various reasons has remained untreated, that 
 in time dilatation has gradually followed. The etiology of the condition 
 has thus been well established as a dilatation due to pressure above the 
 spasmodic contraction and not to a primary atony of the esophageal wall. 
 
 r^ranting then that) spasmodic stenosis is usually a reflex, it becomes 
 interesting to study the sources of the reflex. I lurried gulping of food 
 may cause spasm and thus start what the author has called a "vicious cir- 
 cle" as will be hereafter explained. In the author's experience spasm of 
 the esophagus results in some instances from lesions tli.it themselves pro- 
 duce no sensation. Thus, sujierficial erosions may excite such severe 
 spasms that nothing can be swallowed and yet the patient have no sen- 
 sation except on attempting to swallow, and even then the only sensa-
 
 506 DISEASES OF THE ESOPHAGUS. 
 
 tion is one of obstruction not of pain. Tliis is probably to be explained 
 by the fact that the esophageal pain sense is less efficient than the eso- 
 phageal tactile sense. For, as the autlior has demonstrated, the esophagus 
 is quite insensitive below the cricoid level. Anyone can demonstrate this 
 insensitiveness by swallov^'ing coffee uncomfortably hot. No sensation 
 is produced after the hypopharynx is passed until the stomach is reached 
 and in the stomach the sensation is so slight as sometimes not to be noticed 
 at all. Clinically, we know that esophageal spasm may be secondary 
 to local diseases of the esophagus, or to disease remote from the guller. 
 Thus we have esophageal spasm as a result of li\er disease, probably 
 supernuluced in some instances by engorgement of the veins at the cardiac 
 entl of the eso[)hagus. In certain cases, there are undoubtedly lesions of 
 the mucosa in the esophagus and also in the stomach, which could easily 
 excite spasms, and it is equally certain that stagnation due to the spasm 
 and consequent fermentation of food, detention of secretions and macera- 
 tion could very easily e.xcite or perpetuate the lesions. Thus we have 
 a "vicious circle" in hiatal and abdominal esophagismus. Disease of the 
 stomach may cause severe cases of spasmodic stenosis of the esophagus. 
 The author has seen many cases in which cancer not itself occluding the 
 cardia has produced a hiatal esophagismus that had nearly starved the 
 patient. In other cases observed by the author, gastric ulcer has produced 
 the same condition. Bassler, by post-mortem examination in cases of 
 abdominal esophagismus, has demonstrated the presence of visceral dis- 
 ease above and belovv the diaphragm. 
 
 Spasms of the cricopharj-ngeus and the adjacent circular fibers of 
 the esophagus are in many instances secondary to chronic gastric disease. 
 They are also associated with rajjid gulping of large boluses of food. The 
 latter may be a factor in ])roducing the chronic gastric disorder : but it 
 would seem that it mav also be imlcpendently causative. The presence 
 of s[)asm in cases of organic stricture has been seen b\- all endoscopists, 
 though spasmodic stenosis is rarelv seen in a much infiltrated area. A 
 case of spasmodic stenosis from aphthous ulceration was referred to under 
 "Ulceration of the esophagus." 
 
 A perpetuating cause in established cases is undoubtedly the "'nerve 
 cell habit," and in many cases the presence of an underlying basic neurotic 
 factor is undoubted. In one instance, a patient who was c|uite hysterical 
 would get an attack of abdominal esophagismus whenever anything did 
 not please her. For instance, she took the notion that the endoscopic 
 di\ulsions that we were applying to the abdominal esophagus were tloing 
 her so much good that they ought lo be done every week instead of every 
 two weeks. Regularly the day before the one week was up, her abdominal
 
 DISEASES OF THE ESOE'HAGUS. 507 
 
 esophagus would shr.t up and tliL- dilatation above it would till. L'.y this 
 it is not meant that she had voluntary control of it, but that the emotions 
 sought tiieir outlet through habitual nerve channels, producing a recur- 
 rence of the abdominal esophagismus, which she had had since childhood. 
 This "nerve cell habit" is one of the most frequent causes of recurrences. 
 In the author's opinion the so-called "cardio-spasm" is a pathological 
 prolongation of the physiologic hiatal hesitation in normal deglutition. 
 Esophageal spasmodic stenosis may occur at any age Init. in the author's 
 experience, it is rare after middle life, when muscular activity is on the 
 decline. Spasm of the esophagus in the new-born has been observed once 
 1)\- the autiior. The case was as follows: 
 
 Infant Al., aged two days, was l)rought to the author by Dr. L. C. 
 Manchester for inability to swallow. When it would attempt to nurse 
 the lip and moutii motion were correct and the mouth would till with milk 
 and then the child would choke, cough and strangle and the milk would 
 all run out of the mouth. 
 
 These symptoms justified a suspicion of congenital absence of more 
 or less of the esophagus. The endoscope was gently passed. It met with 
 moderate resistance at the cricopharyngeus and again at the diaphragm 
 but the lumen of the esophagus at these points was iierfectly normal and 
 the si)asmodic constriction gradually yielded to the gentle insinuation of 
 the esophagoscope. Of course the esophagoscopy was done with(jut anes- 
 thesia. There was no sign of the slightest trace of blood on the instru- 
 ment on withdrawal, and best of all, the child immediately took the 
 breast and swallowed perfectly. Four months later when examined by 
 Dr. Manchester it was still swallowing perfectly. 
 
 Remarks. This case seems to have been a si)asmodic stenosis of 
 the fundiform fibers of the inferior constrictor, and of the diaphragm at 
 the hiatus esophageus. The author has been unable to find anv similar 
 case in literature, and feels justified in regarding it as a case of esof^li- 
 agisriiiis in the iicic-horn. The prom])t cure by eso])hagoscopv we see 
 at times in older i)atients, so that it is not at all astonishing that the i)as- 
 sage of the esophagoscope should cure the spasm in the new-born infant 
 where there has been no time for nerve cell habit to liecome fixed. .\n- 
 other interestins?- feature of this case is the demonstration of the harmless- 
 ness of careful esoi)hngoscopy with a small tube (.■) mm.) in a new-born 
 infant. Cuisez and others have stated that esophagoscoi)\ cannot be 
 done in the new-born. \\ hilc the author has always doubted the correct- 
 ness of that statement, no opportunity of controverting it bv actual ex- 
 perience arose until this case, though esophagoscopv in a number of in- 
 fants frcmi two til twcKe months of age bad led me to belie\e that the
 
 508 DISEASES OF THE ESOPHAGUS. 
 
 procedure could be done without anesthesia, and without harm. A num- 
 ber of esophagoscopies in the new-born have since proven equally harm- 
 less. 
 
 In addition to the above-considered secondarj^ manifestations of 
 spasm dependent upon demonstrable lesions near or remote, there is a 
 small number of cases in which there is a spasmodic condition which we 
 must consider primary, and which, for want of a better term, must be 
 called idiopathic, objectionable as that term is, until a definite etiologic 
 basis has been discovered. Doubtless at some not very distant day, this 
 class of cases will be eliminated by the results of the present wide-spread 
 interest in esophageal disease. These cases are doubtless in most in- 
 stances, functional neuroses yf such intricate pathology as to be under- 
 stood only by the trained neurologist. 
 
 Globus hystericus is the name given to the sensation described by 
 patients as a "rising of a lump in the throat," or some such expression. In 
 the cases with this sensation esophagoscoped by the author, there was a 
 contraction of the cricopharyngeus muscle. The reflex impulse may be a 
 neurosis of similar etiology to other hysteric phenomena; but quite often 
 it is e.xcited reflexly by local disease in some part of the esophagus, and 
 consequently calls for esophagoscopy in most instances. It seems prob- 
 able that the choking sensations of grief, and after weeping, and in other 
 emotional phenomena, are due to the same spasmodic condition but, of 
 course, being purely physiological, they do not call for esophagoscopy. 
 The following case illustrates the identity of "globus hystericus" and 
 cricopharyngeal spasm : 
 
 A man of 'il years complaimrd that for years he had had a sensa- 
 tion as of a lump rising in his throat at various times, irrespective of 
 attempts to swallow. Within a year he had been unable to swallow any- 
 thing after twelve o'clock, noon except on a very few days. In the fore- 
 noon swallowing was rarely interferetl with. The author observed on 
 one occasion the patient's attempt at swal'owing. The water was prompt- 
 ly rejected, coming forcibly out of the mouth and nose, accompanied by 
 cough which persisted for a few minutes. A sensation of a lump rising 
 in the throat was complained of for over an hour. A relative stated 
 that the patient ate ravenously in the early morning and at about eleven 
 o'clock. The natient was well nourished, of rather stupid expression, 
 suggestive of the atypical child. The patient mentioned having been 
 examined a number of years before by Dr. Theodore Diller, the neurol- 
 ogist. The author obtained from Dr. Diller the record of a diagnosis 
 of hysteria though at the time of the latter's examination there was no 
 complaint of a lump in the throat nor of anv swallowing symptom.
 
 DISEASKS OF TJIF. KSOPIIAGUS. 501.' 
 
 Examination by the aulhor rexealcd a typical cricopharyngeal spas- 
 modic stenosis. Swallowing wa.-; perfect for a few weeks but the 
 diurnal si)asmodic stenosis recurred, and with it came the sensation of 
 a "lump in the throat." 
 
 The author has seen a few cases somewhat similar to the fore- 
 going but none of them has been cjuite so complete. 
 
 That the early manifestations of numerous forms of organic esoph- 
 ageal disease have been ignored under the label "globus hystericus" is 
 now unquestionable. These cases may or may not be associated with 
 dysphagia. 
 
 Cricot^lnirynycal spasmodic stoiosis. Most cases of cricopharyngeal 
 spasmodic stenosis are unassociated with the sensation of "a lump rising 
 in the throat," known as "globus hystericus," and have no association 
 with hvsteria, though they are often eironeously thus diagnosticated. The 
 disease is essentially a spasm of the circular fibers of the inferior pharyn- 
 geal constrictor known as the cricopharyngeus muscle. The symptomatic 
 characteristic of this affection is dil'liculty in swallowing, which consists 
 in a dilticnlty in stiiitiii(i the food downward. (Jnce the food is started 
 it goes downward unimpeded into 'he stomach. There is no regurgitation 
 of food sometime after swallowing, unless there co-exists in the same 
 case a hiatal esophagismus. These symptoms, however, denote only a 
 high esophageal stenosis. As to whether it is a s])asmodic or an organic 
 stenosis, there is only one way to determine, and that is by esophagoscopy 
 It may even be both organic and spasmodic, the latter secondary to the 
 former. Local malignant disease and foreign bodies ma\- also give rise 
 to spasmodic stenosis. 
 
 Esophiuioscopic appearances oj sf'asiiiodic stenosis at the cricopharyn- 
 geiis. High spasm of the esophagus unassociated with dixerticuhini, may 
 not show a typical form as disting'iished from the spasm that always oc- 
 curs on the introduction of an eso])hagoscope. In other instances, there 
 will be a slight clamping at the cricopharyngeal le\el. the pictures then 
 being of a small point of lumen from which radiate slight creases or 
 folds. In other instances, the folds are not so ajjparent. but the point 
 is in the center of an almost mammilliform projection. In other instances 
 the opening in the |)rojection will be slit-like in form with the anterior 
 and posterior lips meeting in the lenter line, the slit being more or less 
 transverse. In some instances there is a curved slit, or the lips may 
 bulge upw-ard toward thf obser\er. .\11 of these pictures are occasional- 
 ly seen in the normal esophagus, iluring examination without anesthesia. 
 Nevertheless they are s])asm j)ictures, and when they occur in the normal 
 esophagus, they indicate simiilv the sjiasm that occurs reflexl\- from the
 
 •">l(l DISEASES Ol- THE ESOPHAGUS. 
 
 presence of tlie tube. AMien we encounter a patient who says that sud- 
 denly while eatit^g he will choke up and food will not go down, and upon 
 esophagoscopy we tind any of the above pictures, and especially if the 
 spasmodic picture is shown in connection with a more than usually un- 
 yielding closure, and when, furthermore, the spasm gradually yields and 
 the esophagoscope of full size goes through readily without further re- 
 sistance, indicating a normal-sized esophagus — under such circumstances 
 we are justified in making a diagnosis of spasm of the upper end of the 
 esophagus. It is only tlie esophagoscopist of large experience who can 
 distinguish between a n(irnial degree of spasm excited by the tube 
 in a normal case, when the tube is passed without an anesthetic, and the 
 case in which there is a pathologic degree of spasm. Furthermore, it is 
 absolutely necessary to be certain that the esophagoscope is properly 
 pointed, that is, that its axis corresponds precisely with the axis of the 
 lumen of the esophagus, and that it is not impinging more upon one wall 
 than upon the other. The closed lumen may open uji momentarily when 
 the patient gags or attempts to vomit, or, more likely, when the patient 
 takes a deep breath after a continuous strain of vomiturition. Since 
 there is always more or less spasmodic obstruction to the introduction of 
 the tube at the upper end of the esophagus, the beginner will find great dif- 
 ficulty in distinguishing the difference between a normal and pathologic 
 spasm, and even the most experienced will, in a few cases, be in doubt. 
 
 Treatment of spasmodic stenosis of the esophagus at the crico- 
 pharyngeal leicl. All cases associated with a morbid source of reflexes, 
 near or remote, should be cured of the basic lesion. A few of such cases 
 and all of the purely functional cases can be cured by the passage of a 
 large esophagoscope. Recurrences may reeiuire similar treatment at 
 intervals for a year or two, but many cases are cured by a single treat- 
 ment. 
 
 Hiato! csopha(/isiniis (so-called "cardiospasm").* L'ndoubtedly the 
 old word "cardiospasm," like many of the oUl words of medicine, cov- 
 ered a number of different conditions of independent etiology and pathol- 
 ogy. The word cardia is ])roperly used as the name of the esophageal 
 orifice of the stomach. Spasm limited solely to this orifice, is certainly 
 exceedingly rare, while spasm of the abdominal esophagus and of the 
 esophagus at the hiatus, either separately or together, are relatively com- 
 mon, and should be called by their proper names. The word "cardio- 
 spasm" should either l)e dropped as a misnomer or limited to those rare 
 cases of true cardial esophagismus. Brown Kelley has demonstrated the 
 
 •Liberal quotations are made in the following pages from the author's "Kap- 
 port" to the International Medical Congress, Section XV, London, 1913.
 
 DISKASES OK TlIK KSOPIIAGUS. 511 
 
 experimental fact that section ai ijoth vagi, without stimulation, is 
 followed by dilatation of the lower part of the esophagus and contractioi: 
 of the cardia. which he rightly says corresponds to the supposed condi- 
 tion in cariliospasm. I'.ut as a clinical morbid entity, such a condition 
 is rarel}', if ever, found in the disease commonly known as cardiospasm. 
 
 The author's contention in his earlier book ( I5ib. 2(i!l, p. 271 ) that 
 the so-called "cardiospasm" was in reality, in almost ail instances, more 
 properly a hiatal esophagismus or phrenospasm, was based purely upon 
 endoscoi)ic clinical observation. Recently, however, in a very interesting 
 monograijh. Liebault ( Bib. ;?2!l ) has furnished the anatomical basis for 
 the obser\ation. I'Voni careful dissection he has found the muscular 
 fibers which are so active in a sphincteric action of the esophagus at the 
 hiatal level, as shown in the drawing Fig. 41<i. (Jn investigation, he 
 fovmd that Rouget had described the local anatomy in essentially the same 
 way. He quotes Kouget's description as follows : 
 
 "The muscular fibers of the sphincter, slightly paler than the rest of 
 the muscle, slender and not numerous, leave each crus at the level of the 
 hiatus and pass to the esophagus, with wdnose fibers they are interlaced 
 terminating by the formation, on the anterior aspect, of loops interlacing 
 with those of the opposite side. The small muscular bundles, more or 
 less developed but constant, ordinarily exist only on the sub-diaphrag- 
 matic portion of the esophagus. In one instance, I found a thin muscular 
 lamina 1 cm. in size which extended from tl.e left crus to the cardia, end- 
 ing by spreading its fibers over the anterior wall of the stomach. I have 
 almost always found the esophagus and cardia united at the external 
 border of the left crus by a lamina of fibrillar ajiiJcarance but endowed 
 with special elasticity such as characterizes the dartos, and which is 
 found also at the level of the terminal loops of the cremaster in the adult." 
 Liebault adds, "Classically, the hiatus is described as of elli])tic form 
 and such, indeed, it appears to be on inspection from above, but on ex- 
 amination of its abdominal aspect it appears rather that the esophagus 
 has insinuated itself between the diaphragmatic libers, which it has 
 spread apart in order that it mav enter the abdominal cavitv. It is not 
 an elliptic orifice, but rather a cleft througli which the esuphagus passes. 
 I.iebault agrees with others who havt been unable to demonstrate any 
 increase in the circular fibers at the true cardia as com])ared with the 
 circular libers of other [xntions of the esophagus. 
 
 In further confirmation of the author's contention ( llib. 2i)!) ) against 
 the misleading word "cardiospasm," anatomic study, in addition to the 
 demonstration by Liebault above <|uoted, has also demonstrated the al)- 
 sence f)f anything th;it could be c;dled a sphincter at the cardia. and the
 
 512 
 
 DISUASKS OF THE ICSOPHAGUS. 
 
 narrowing at this ])oint that has been shown in so many text books on 
 anatomy is a misfortune. Hill quotes McAllister to tlie effect that there 
 is no histologically demonstrable siihincter and he states that the circular 
 musculature at this point is weak. Brown Kellv and \\'illiamina .\ble, 
 
 Fig. 410. — Drawing of the under surface of the diaphragm showing the con- 
 stricting musculature at the liiatus. (After Liebault). 
 
 by careful special dissections, ha\e demonstrated that "it is quite ap- 
 parent to the naked eye that both muscular coats are of uniform thickness. 
 and that no special aggregation of fibers exists at or near the cardia," and 
 that "nothing was found in any of the dissections or in the anatomical
 
 DISEASES OF THE ESOPHAGUS. 513 
 
 works consullctl tu justify Dr. Hill's statcnicm thai ihc circular fiber 
 musculature was specially weak ui this region." 
 
 IVrsoually, the author believes that it is only very rarely, if ever, 
 that any spasm exists below the hiatal level, but in order to place the 
 study on a systematic basis, he believes that, as endoscopists, it would be 
 better for us to abandon the word "cardiospasm" and to substitute for it 
 the three clinical types, that may possibly be made out : namely, 
 
 1. Hiatal esophagismus. 
 
 2. Abdominal esophagismus. 
 •3. Cardial esophagismus. 
 
 That the constriction in so-called "cardiospasm" is first encountered 
 at the hiatus no one who knows the hiatal esophagus when he sees it 
 can deny. And no experienced observer can deny that after the tube- 
 mouth has passed the hiatal constriction it goes through the two to four 
 centimeters of abdominal esophagus into the stomach with Init little 
 resistance, which lessens as the stomach is approached. The degree of the 
 resistance of this abdominal esophagus varies. In most cases the author 
 has fell inclined to regard it as so slight that he would dismiss it as a 
 factor in spasmodic stenosis if it were not for two things: 1. The pos- 
 sibility of its relaxation simultaneously with the hiatal yielding; and, (2) 
 the radiographic studies. With the question in mind he has watched the 
 yielding of the abdominal esophagus as the hiatus is passed and he feels 
 inclined to say that abdominal esophagismus does not exist except in 
 conjunction with hiatal eso])hagismus. Further, if cardial esophagismus 
 exists, (the author has obserxed only three cases which he would feel 
 justified in classing as such) it does not exist except in conjunction with 
 hi;ital esophagismus, or as the author first called it, phrenospasm. A 
 study of the ra(liograi)hs such as Figs. -Ill and 413, reveals the possibil- 
 ity of two interpretations. The narrow streak of bismuth shadow be- 
 low the very evident hiatal constriction might indicate either a spas- 
 modically contracted lumen of Mie whole abdominal esophagus, or a 
 trickling stream of leakage that was escaping through the almost tightly 
 shut hiatus above. As a matter of fact we know that the food in these 
 cases of spasmodic stenosis does leak through gradually, rarel>. if e\er, 
 suddenly. l'"urtlier in\ estig.'itiiiu nf this point is needed. l'"rom esophago- 
 scopic observations, the author knows that the hiatal esophagus is ligiilly 
 contracted in the disease known as "cartliospasm." 
 
 Hiatal esophagismus, even more than di\ ertieulum, reminds one nf 
 the ingluvies of birds, inasmuch as the dilated esophagus fills (|uickly, 
 and yet there is a constant leakage, which allows a certain proportion 
 of the food to pass on through at a relatively slow rate. In one of the
 
 514 DISKASKS OF THIC ESOPHAGUS. 
 
 author's patients, the cure of the abdominal esophagismus by divulsion, 
 resulted in food going through so promptly into the stomach, that taking 
 food excited nausea lor quite a long time until the stomach became ac- 
 
 FiG. 411. — Radiograph ol a woman of 45, shoiNiiij; an abdominal isoiihagismus 
 vvliich was afterward cured by endoscopic mechanical divulsion. The "flat floor" of 
 the dilatation shows why previously used blind methods had failed to introduce 
 any instrument through the hiatus. 
 
 customed to the unusual sensation of having food go through directly 
 when swallowed. Patients afflicted with spasm of the abdominal esoph- 
 agus usually complain of distress after eating and regurgitation of food 
 within a period of from a c|uarter of an hour to several hours after eat-
 
 DISEASES OE THE ESOPHAGUS. 
 
 51 o 
 
 iiig. At limes, especially if ihe sac be large, there will be no regurgitation 
 for a number of days, when a large quantity of stale food may come up. 
 In many instances, hiowever, but a very small quantity of food is re- 
 gurgitated, though the accumulation be large. It will pass gradually, a 
 
 Fu;. 41J, — Ka(li(i};ra])Ii (jf a woman of 2.S, sliowinn an abiluminal esnpliaHismus 
 with only very slight dilatation above it. The deviation of the esophagus by the 
 aorta was verified csophagoscopically (Author's case. Radioyrapli made by Hr. 
 J. C, Bowen), 
 
 little at a time, as the spasm relaxes, into the stomach and usually (though 
 not always) before a serious state of inanition supervenes. The symp- 
 toms are not meant as in any way diagnostic. There are no absolutely
 
 516 DISEASES OF THE ESOPHAGUS. 
 
 diagnostic signs of esophageal disease, and the author in tlie present 
 work has referred but little to them. The fact of the matter is that any 
 patient coming in with any symptoms whatever that could be possibly 
 referable to the esophagus, requires an esophagoscopy. Any sort of diag- 
 nosis based upon signs and symptoms is so apt to be erroneous, that it is 
 not worth while to more than make a decision that the symptoms justify 
 
 Fig. 413. — Radiograph of a woman twenty-two years of age, affected with 
 hiatal esophagismus simidating diverticulum. The shadow of the bismuth porridge 
 rests upon about i^ liters of stale food in an enormous dilatation as demonstrated 
 esophagoscopicilly after emptying. (Author's case). 
 
 esophagoscopy. For instance, all the signs of cancer of the esophagus 
 may be present and yet the esophagoscope will show nothing more than 
 spasm of the hiatal esophagus. The exact reverse may be true and the 
 patient may have all the symptoms of abdominal esophagismus for many, 
 many years, and yet esophagoscopy may show an incipient or even well- 
 developed cancer which has arisen u])on the site of some inflammatory 
 area within the esophagus.
 
 nisKASKs 01" Tine i^sopiiagus. 
 
 517 
 
 The diagnosis of hiatal csoj^ha^/isinus is easy in the t\pical case witli 
 an enormons dilatation, a white, pasty, macerated mucosa, and a con- 
 tracted esophagus which, however, permits a large esophagoscope to pass 
 into the stomach after a delay at the hiatus; hut in the early, or in the 
 less typical cases, without dilatation it is often exceedingly ilitilcult to dis- 
 tinguish between purely spasmodic conditions and those of local lesions 
 in the neighborhood of the esophagus but not themselves showing in 
 compressions or very marked deviations of the abdominal esophagus. Tn 
 such cases, while many esophagoscopists feel sure of their diagnosis, many 
 
 Fig. 414. — Lateral radiograph of same patient as in Fi.n. 41.?, the shadow of 
 liie bismuth mixture simulating diverticuUim. The mass of food after eating 
 protruded in the neck and could be evacuated by external pressure with the pa- 
 tient's hand. 
 
 do not agree as to what the endoscopic pictures are, and many endos- 
 copists describe a i)icture which is seen by other endoscopists in the per- 
 fectly normal esophagus abdoniinalis. It is in such cases that the bis- 
 muth radiograjih, useful in anv case, is of especial value. The best of all 
 methods, however, is by the trained sense of touch which by long experi- 
 ence c|uickly detects more than normal resistance at the hiatus. This 
 must be determined, and the experience must be acquired by esophagos- 
 copy without general anesthesia because in deep anesthesia there is no 
 resistance, and partial anesthesia introduces a variable element. Local
 
 518 
 
 DISKASKS 01' THK ESOPHAGUS. 
 
 Fig. 415. — Radiograph of a woman of thirty-eight years. The shadow, which 
 so much resembles a diverticulum, was esophagoscopically proven to be a dilata- 
 tion above a stricture of probably luetic origin. The stricture is behind and above 
 the bottom of the lower border of the shadow of tlie dilatation. Endoscopic dilata- 
 tion resulted in a cure, after which a bismuth mixture went through into the 
 stomach so promptly as not to show in a radiograph. Fluoroscopic examination 
 showed swallowing to be normal. (Radiograph by Dr. Russell H. Boggs.) The 
 lower illustration shows the endoscopic appearance of the suprastrictural dilatation. 
 The orifice of the stricture is hidden by tlie overhanging, whitish, cicatricial fold.
 
 DISEASES CI- THE ESOPHAGUS. 519 
 
 anesthesia has Init little and a very uncLitiin influence on relaxation of 
 spasm. Radiography may lead to error as in the case illustrated in Fig. 
 41;^, 41J, and ll."). 
 
 The possibility of the radiograph being taken just before normal 
 physiologic opening of the abdominal esophagus in the deglutitory cycle 
 must be borne in mind in the interpretation of radiographs. It is to 
 be eliminated in each case by the comparison of a number of plates, and 
 by the elapsed time. 
 
 Treatment cf hiatal esophagismus {so-called "cardiospas>n"). Treat- 
 ment of abdominal esophagismus and hiatal esophagismus, has led to 
 the devising of a number of difl:"erent water-bags and air-bags, which 
 have \ielded good results. In some cases, however, it is impossible to 
 introduce them. The author's personal preference, like that of Briinings', 
 is for a mechanical divulsor inserted through the esophagoscope where 
 the sense of touch and the precision of a steel instrument give one an 
 accurate control. Heavy, spring-opjiosed handles are a mistake as they 
 prevent the safeguarding of the divulsion by the delicate sense of touch. 
 The autlior uses the di\iilsor that Moshcr devised for the rapid dilatation 
 of cicatricial strictures, Fig. IS. The method is simple. The 53 cm. 
 esophagoscope is passed into the stomach until it reaches the greater 
 curvature. Then the divulsor. closed, is passed through the esophago- 
 scoj-e until the distal enc' of the divulsor touches the greater curvature of 
 the stomach. Then the esojjhagoscope i,s withdrawn until the slightly ex- 
 panded expansile portion of the di\-ulsor is endoscoi)ically seen to be all 
 exposed beyond the Inbe-mniuli. I he partial withdrawal of the eso[)h- 
 agoscope is done under the guidance of the eye so that the largest diam- 
 eter of the divulsor can be seen to be in the hiatal esophagus. It is then 
 expanded to the lull |iliysiological size, about ?il to 'i') millimeters in the 
 adult, unless resistance to expansion is felt, (".reat care is necessary not 
 to use undue force which might ru])ture the esophagus ; but the trained 
 touch will do no hartn. The dilaioi'. tully expanded in the living patient, 
 is shown in the radiograph, ]'\g. I ji,. Tbe divulsor is allowed to remain 
 in its expanded position for from live to ten minutes. It is then con- 
 tracted with the screw mechanism, great care being used to avoid pinch- 
 ing the mucosa as the blades close. If there is any teudeucy to this, the 
 blades should be re-e\panded slightly and the divulsor rotated gently. Di- 
 vulsion is somewhat painful and the use of ether anesthesia is a<lvisable, 
 not onlv for this reason, but especially to prevent xomiting while the di- 
 vulsor is fi'.lly expanded winch mi.trht cause tr;uim;i. I'Vom one to six 
 divulsions at intervals of a week are necessary.
 
 520 
 
 DISEASES OF THE ESOPHAGUS. 
 
 It is necessary after any form of treatment to instruct the patient 
 to eat very slowly and to masticate very thoroughly. It is altogether 
 probable that very rapid eating and insufficient mastication may, in some 
 instances, be one of the factors contributing to the cause of spasm of the 
 esophagus, because we know that in certain instances small foreign bodies 
 will cause a spasm, as evidenced by complete obstruction of the esoph- 
 agus by a foreign body too small to block up the canal. Liquid foods 
 
 Fig. 416. — Divulser fully expanded (24 mm.) in the living patient, a man 01 
 twenty-one years. The double image is due to respiratory movement. 
 
 taken in very small (|uantitifs frequently repeated are best during the 
 treatments and for a month or longer thereafter in order to permit reso- 
 lution of the macerated, inflamed esophagus. L'ndoubtedly there are a 
 few cases that are prone to recur, and the most stubborn are those ex- 
 isting since childhood, with consequent infantile stomach and long-estab- 
 lished "nerve cell habit." The neurologist should be called in consultation 
 in cases that do not yield promptly to divulsion.
 
 DISEASES OF TIIK ESOPHAGUS. 521 
 
 The foregoing is the method that has yielded the author the best 
 resuhs. There are a number of otlicr methods successfully used by Plum- 
 mer, Jesse Meyer, Lerche and others, ?.nd their writings, reference to 
 which will be found in the Bibliography, should be consulted. 
 
 Dilating bags filled with air or water after insertion on the prin- 
 ciple of Horrock's maieutic are e*Tfective if accurately placed. It is so 
 difficult, however, to place them accurately by blind methods, that esoph- 
 agoscopic placing seems preferable to the author, who, however, may 
 be biased. Gastrostomy through the abdominal wall with retrograde 
 dilatation of the cardia has been done quite a number of times, but in 
 view of the beautiful results that are obtainable endoscopically, such pro- 
 cedure seems unjustifiable, until endoscopic methods have utterly failed 
 to cure. It is difficult to see how any more thorough stretching can be 
 done from below than could be done from above. Gastrostomy for feed- 
 ing is, usually, contraindicated because a stomach tube can be placed with 
 the esophagoscope, if a case is encountered where the spasm is so severe 
 or the superjacent diffuse dilatation is so great that the stomach tube 
 cannot be passed otherwise. The author has seen a number of cases 
 where the stomach tube could not be passed because the patient could 
 not aid by swallowing efiforts, and the stomach tube would strike the flat 
 floor (See Fig. 411) of the dilatation and had no tendency to enter the 
 hiatal esophagus. In all such cases the author has found it exceedingly 
 easy to introduce the gastroscope and through it to pass a soft rubber 
 stomach tube for feeding. The gastroscope was withdrawn, leaving the 
 feeding tube in situ. In case an endoscopist is not available, gastrostomy 
 for feeding is, of cotirse, advisable before the patient's nutrition has suf- 
 fered too much. Duodenal feeding through the duodenal feeding tube 
 has been used with excellent results by Clement R. Jones, T. W'ray Gray- 
 son and others.
 
 CHAPTER XXXII. 
 
 Diseases of the Esophagus.- Continued. 
 
 CICATRICIAI. STEXOSIS OF THF, ESOPHAGUS. 
 
 Etiology* The most common cause of cicatricial stenosis is the 
 swallowing of corrosive poisons, especially caustic alkalies. It is a pitiable 
 thing to see little children threatened with starvation because of a cica- 
 tricial esophageal stenosis due to the swallowing of some form of caustic 
 alkali to which the laxity of our laws permitted them to be exposed. The 
 law requires that the druggist shall label corrosive poisons "Poison" and 
 the careful druggist adds antidotal advice. Next door to the druggist, 
 the grocer sells corrosive poisons having on the label no hint of caution, 
 but having directly misleading statements, such as "Will not hurt the 
 hands," "Will not harm the most delicate fabric," etc. It is the general 
 impression that concentrated lye is a relic of the old days of home-made 
 soaps, but investigation shows that it is in common use in the household 
 for labor-saving cleansing of all kinds. Its harmful effect on the hands 
 conveys to the thoughtful some hint of the caustic nature of its con- 
 tents. But the frequency with which patients with esophageal stricture, 
 following the swallowing of concentrated lye. come in an almost fatal 
 state of inanition to the esophagoscoinst, is an index to the thoughtless- 
 ness of the users of concentrated lye. and an urgent call for legislation 
 that shall compel the manufacturer to label concentrated lye containers 
 "Poison" and to state a few antidotes, even if this does diminish slightly 
 the sale of such products. Esophageal stricture from the swallowing 
 of commercial lye has been for many years a lesion of common observa- 
 tion by those interested in the esophagus. The frequency declined with 
 the more general substitution of cheap commercial soaps for the home- 
 made products ; but concentrated lye is stil! in extensive use for general 
 
 *Part of this section on etiology is revised, with .additions, from the author's 
 'Chairman's Address" to the Section on Lar.vnprologry of the American Medical 
 Association. 1910. (Bib. 241.)
 
 IMSKASES OF TIIK I-SOI'Il AGIJS. 523 
 
 scrubbing ami cleansing purposes. Furthermore, strictures of the esoph- 
 agus are again on the increase owing to the flooding of the market with 
 a large number of proprietary "cleansers" for household use and "wash- 
 ing powders" for laundry use. The author has seen three cases of the 
 most severe ulceration and sloughing of the esophagus from the swallow- 
 ing of strong solutions of three of these proprietary preparations. The 
 author has had the preparations analyzed and all contained similar in- 
 gredients : an abrasive, a strong powdered soap, and a caustic alkali : 
 namely, soda ash. The proportions varied from eight per cent in the 
 "cleansers" up to forty or fifty per cent in the laundry powders; but in 
 none was the corrosive alkali so diluted as not to be caustic to the deli- 
 cate esophageal mucosa of a child. And, worst of all, the mixture was 
 not thorough ; therefore some portions were more concentrated than 
 others, so that under certain conditions it would be possible for a child 
 to get a concentrated dose of caustic. Another thing which doubtless 
 contributes to the danger is the insoluble nature of the abrasive and the 
 slower solubility of the soap. Thus, a litde water dissolves out the al- 
 kali in strong solution. The accident in a number of cases occurred 
 thrtjugh the child's swallowing the ringings of the almost empty can. The 
 economical mother was endeavoring to extract the dregs for use ; and, 
 totally unsuspicious of a i)rcparation wliicb. could not "injure the most 
 delicate fabric," did not place the can oat of reach of the child. In an- 
 other instance the cleansing powder had been sprinkled on the dishes in 
 the dish-pan. From one cup it was not removed by rinsing, the powdered 
 soap in its composition making it adherent, and from this cup the child 
 drank. In the third instance the child drew water from a faucet into a 
 cup that had been used to measure out a quantity of a proprietary wash- 
 ing powder for laundry use. On not one of the containers of these three 
 widely advertised proprietary caustic prei)arations was there one hint 
 of the dangerous nature of the contents. .Vmmonia, "salts of tartar" 
 (potassium carbonate), mercuric bichloride, strong acids, etc.. are less 
 frequent causes of cicatricial stenoses. It was at one time supposed that 
 cicatricial stenosis of the esophagus was invariably due to the swallow- 
 ing of corrosives. It is <|uite well established now, that tuberculosis, lues, 
 scarlatina, diphtheria and various pyogenic conditions can j^roduce ul- 
 ceration followed by cicatricies in the esophagus. MacReynolds reports 
 the discovery at autopsy of a large area of ulceration in the esoj^hagus of 
 a patient who died of spontaneous rupture of the esophagus, complicating 
 mastoid disease. Chronic esophagitis from spasm with stagnation of 
 food and secretions, as seen in abdominal and hiatal esophagismus, (er- 
 roneously called "cardiospasm" I may result in superficial erosions which
 
 524 DISEASES OF THE ESOPHAGUS. 
 
 when the pyogenic infections become engrafted upon them, may result 
 in serious cicatrices. Thus we have an organic stenosis following upon 
 a spasmodic stenosis. Every esophagoscopist of large experience has 
 seen cases of cicatricial stenosis of the esophagus in which he is utterly 
 at loss to discover the original caiise of an undoubted cicatricial stenosis. 
 The so-called "peptic" ulcer of the lower portion of the esophagus may 
 be a cause. Observations by Guisez, MacKinnie and also some observa- 
 tions of the author point clearly to the fact that spasmodic lesions can 
 produce organic stricture by the erosions due to the accompanying esoph- 
 agitis. Decubitus ulcer of typhoid fever has caused cicatricial esophageal 
 stenosis. The author has previously pointed out the occurrence of an 
 ulcer in the esophagus from sphacelus of the esophageal mucosa in the 
 low ^•itality of profound typhoid toxemia. Since that time five cases of 
 post-typhoid stenosis from cicatricial contraction have been sent to the 
 author. In four of these cases the cicatrix was at the cricoid level, evi- 
 dently due to the pressure of the cricoid against the vertebral column, 
 pinching the esophageal wall, the vitality of which was lowered 
 by the typhoid toxemia, ending in sloughing and ulceration. In the other 
 case the cicatrix was at the level of the crossing of the left bronchus. 
 Whatever be the nature of the original lesion the stenotic cicatrix is usual- 
 ly the result of the inflammatory infiltration resulting from the pro- 
 longed ulcerative processes due to the secondary mixed pyogenic in- 
 fections. Any sort of stenosis of riie esophagus, if long continued, may, 
 by the stagnation of food and secretion, set up esophagitis and ulceration 
 resulting in cicatrices. In view of this, slight degrees of congenital 
 stenosis may be considered, possibly, a contributing cause. As pointed 
 out by Brown Kelly (Bib. 303) slighter degrees of organic stenosis, in 
 some instances possibly congenital, may have existed for years un- 
 noticed by the patient. Cicatricial stricture of the esophagus may fol- 
 low prolonged sojourn of a foreign body. The presence of a foreign 
 body results in a localized ulceration with hy]:)erplasia. During a pro- 
 longed period, this round-celled infiltration increases and later, after the 
 foreign body is removed, the contraction of the cicatricial tissue results 
 in a greater or less stenosis of the esophageal lumen. In one case of 
 this kind, seen by the author, in a child four years of age, a coin had been 
 removed by a general surgeon by external esophagotomv after the coin 
 had been in situ for nearly one year. After the wound had healed, the 
 child could swallow quite well, but in a few weeks difficulty in swallow- 
 ing began to appear, becoming gradually worse until at the end of two 
 months a very severe degree of stenosis was present, permitting only 
 liquids to pass. The author cured the stricture by forcible dilatation and
 
 DISEASES OF THE ESOPHAGUS. 525 
 
 continued bouginage f^er tubain. It seemed to be very mucb more amen- 
 able to treatment than the stricture cases following the swallowing of 
 lye, and the stricture was only single, while those following the swallow- 
 ing of caustic alkalies are usually multii^le, the openings not being con- 
 centric. 
 
 Site of cicatricial stricture of the esophagus. The author's experi- 
 ence has been quite at variance wi'.h that of Guisez. The latter reports 
 that out of 38 cases due to corrosives the site of predilection for the 
 cicatricial stricture was at the cardia, and when there were more than one, 
 the next most freciuent site was the upper orifice, the tightest being at 
 the cardia. In the author's experience, he has ne\er seen a case of stric- 
 ture due to caustic situatetl at the cardia. Uut of a total of 21 of this 
 class of cases, 18 were in the middle third of the esophagus, ti at the 
 level of the hiatus, 4 near the cricopharyngeus. Where the strictures 
 were multiple they were usually quite close together, though in three 
 cases there was a stricture just below the cricoid and another in the 
 middle third. Uf the cases in the midlle third, the most frequent site 
 was at about the crossing of the left bronchus. Stricture of the pylorus 
 as well as of the esophagus following the swallowing of a corrosive has 
 been reported by Hruel. ( Bib. ."iU.) 
 
 Prognosis. I'lUreated, the mortality of cicatricial strictures of small 
 lumen is very high. Slighter degrees of stenosis are prone to increase 
 from stasis, esophagitis and secondary ulceration. By early gastrostomy 
 witii proper feeding inrough the tube, life may be prolonged indefinitely. 
 As a matter of fact, however, old people who have worn a gastrostomy 
 tube since childhood are never seen. Statistics from which the causes 
 of death might have been determined are lacking. Doubtless mortality 
 would have been less if gastrostomy had been done earlier. Under blind 
 methods of treatment the patient was almost certain, sooner or later, to 
 succumb to perforation by the bougie, the danger increasing as the super- 
 jacent dilatation increased, rendering more and more difficult the finding 
 of the strictural orifice. The i)rognosis of cicatricial stenosis of the esojjh- 
 agus untreated is unfavorable so far as recovery is concerned. There 
 probably is never a comjilete spontaneous recovery. Occasionally slight 
 Strictures may become temporarily stenosed with food, or the stenosis 
 may be increased by swelling, producing, for a short period, a very severe 
 .stenosis. This m:iy subside .'md a condition of relative cure so far as 
 dysphagia is concerned may result, and the patient rnay be quite comfort- 
 able ; but this is only the disappearance of a relatively temporary condi- 
 tion. In regard to danger to life, the prognosis in cicatricial stenosis of 
 the esojjhagus is good if an early ga>trostomy is done and (he feeding
 
 526 DISEASES OF THE ESOPHAGUS. 
 
 is carefully followed out according to a well planned dietary'. The fore- 
 going represents the prognosis of cicatricial stenosis before the develop- 
 ment of endoscopic treatment. L'nder modern methods the prognosis is 
 favorable as to ultimate results, though some of the cases require a long 
 period of treatment, the duration depending upon the number of strictures, 
 the presence or absence of pouches between the strictures and the previ- 
 ous duration of the condition, as well a; upon the tightness of the stricture. 
 In recent cases where there is but a single stricture or two strictures, the 
 lower one of concentric lumen, the cure is rapid and the results excellent. 
 On the other hand, in multiple strictures, not concentric, and of long- 
 standing, with extensive tibrotic changes in the esophageal wall, due to 
 
 Fig. 417. — Photograph of a child, twenty months old, a victim of cicatricial 
 esophageal stricture. It is in the act of inducing vomiting by the insertion of its 
 fingers to the fauces, a self-discovered means of relief, quite remarkable, consider- 
 ing the age. Referred by Dr. F. LeMoyne Hupp. 
 
 prolonged chronic esophagitis, and especially if the lumen of the stricture 
 is exceedingly small — in all such cases, the treatment is ver\- much more 
 difficult, and though the ultimate prognosis is not unfavorable, the treat- 
 ment will be prolonged by recurrences. As to mortality under endoscopic 
 methods, the author has never yet lost a case. The only death occurring 
 in his clinic was from blind bouginage before his present endoscopic 
 technic was developed. 
 
 Symptoms. Lengthy consideration of the symptoms is not now- 
 necessary, as it was in the days of the often erroneous deductive diag- 
 nosis. If a patient has any trouble in swallowing or regurgitates or 
 "vomits" his food 01 chokes or coughs when attempting to swallow, 
 esophagoscopy is indicated and deductive or blind instrumental attempts
 
 DISEASES OF THE ESOPHAGUS. 527 
 
 at diagnosis are time-wasting, misleading and utterly useless. It requires 
 but a few minutes w-ithout an anesthetic, general or local, to look at the 
 eso]>hagus with the esophagoscope and make a positive diagnosis of cica- 
 tricial stricture. Radiography is useful in excluding aneurysm and in de- 
 termining the presence of a stenosis and the extent of the dilatation above 
 it. That the stricture is cicatricial can be determined only by esophagos- 
 cnpy. The most usual comjilaints of the patients are difticulty in swal- 
 lowing, cough, and regurgitation. Distress after eating, to be relieved 
 only by regurgitation is seen in low strictures (Fig. -ll'i ). 
 
 Esopliagosco/yic af^pearances and diagnosis of cicatricial stricliirc. The 
 endoscopic picture in a typical case is easily recognized, but it may be 
 masked by various conditions other than the cicatrix. If there is com- 
 plete stagnation, or if the patient has recently eaten, fragments of food 
 may be noticed adherent to the walls of the esophagus, or lodged in the 
 pockets existing below the first stricture, or in the case of a recent and 
 illy-masticated meal there may be (|uite an accumulation above the stric- 
 ture. (Jften it will be found that the patient has come for a complete 
 stenosis, which, upon examination is found to be due to the lodgment 
 of a particle of food acting as a cork in the lumen of the stricture. This 
 does not occur as often as might be supposed for the reason that the 
 patients usually learn that, by inserting their finger back uf the tongue and 
 causing a regurgitation, food particles can be, in most instances, dislodged 
 and regurgitated. If the food has remained for any length of time in the 
 esophagus, decomposition has occurred and in case of nitrogenous fooil, 
 the odor may W very foul. In case of starchy foods and sugar, there 
 will be usually a sour odor. This is not the normally sour odor of 
 stomach contents, but a peculiar odor due to the fermentation of starches 
 and sugars. .Ml food and sccretinns must be removed and the mucosa 
 sponged clean. If there has been no stagnation the color of the cicatricial 
 pf)rtion^ of the esojihageal wall is usually paler than normal, and may be 
 decidedl} white and blanched. \^essels are often \i^iblc in tliis white tis- 
 sue. In certain cases there may be patches of reddish, acutely inflamed 
 mucosa, and if there is very much dilatation above the stricture, there may 
 be a macerated condition of the esophageal mucosa. Where the mucosa 
 has been uninjured by the caustic, the epithelium may be furred up and 
 pasty in appearance from maceration. The ei)ithelium covering the cica- 
 tricial tissue does not usually fur up to the same extent and may be quite 
 smooth and shining in marked contrast to the furred epithelium in the 
 ])ortions undamaged by the corrosion. Whitish spots of erosion and c\en 
 ulceration may be visible at certain points I Fig. 12, Plate III). It is 
 (|uite likelv that these erosions play an iiiiportanl part in lb',- increase of
 
 5*<JS DISEASES OF THE ESOPHAGUS. 
 
 the stenosis and the diminution of the strictural lumen through contrac- 
 tion and fibrosis of the round-celled inflammatory infiltrate, constituting 
 what the author has called a "vicious circle." The scars from the swallow- 
 ing of caustics in some instances are linear and seen in perspective, they 
 appear wedge-shaped from foreshortening (Fig. 12, Plate III and Fig. 
 4, Plate III, Bib. 2()9). They are in some instances depressed below the 
 surface of the mucous membrane, though in other instances they may 
 project toward the lumen in a more or less cord-like way. In other cases 
 they are flush with the neighboring mucosal surface. In passing down a 
 cicatricial esophagus very often there is a very noticeable absence of the 
 normal radial creases. The cicatricial tissue in a cicatricial stenosis may 
 take the form of a band running across in any direction and causing 
 more or less flattening of the circular outline of the lumen at that point 
 Exactly annular strictures occur and occasionally they are most beauti- 
 fully .symmetrical and funnel-shaped. As a rule, however, they are more 
 or less eccentric, and their outline is more or less oval, or angular. Where 
 the amount of cicatricial tissue is small, the outline is not fixed but 
 changes with the respiratory movements and even with the transmitted 
 cardiac impulses, antiperistalsis and movements imparted by the esophago- 
 scope. If the first stricture encountered is not very smal!,. the view 
 through the stricture usually is that of a cavity below. In this cavity it 
 is very rare to see the lumen of strictures which usually exist below, be- 
 cause the lower ones are not concentric with the upper ones, nor are their 
 lumina easy to find. If the upper stricture is not very tight and the 
 lower one is smaller, there is a strong tendency to pouch formation from 
 the pressure of food accumulating between the two strictures. 
 
 Differential diagnosis. In a typical case, a cicatricial stenosis is 
 readily recognizable by the descriptions already herein given, but there 
 are cases in which a diagnosis is extremely difficult because of associated 
 lesions. When inflammatory conditions and ulceration are present, they 
 must be first treated by a rest in bed, very careful restriction of the 
 diet as to quantity, and all food should ue licjuid. Bismuth and calomel 
 taken dry on the tongue in small quantities at frequent intervals, with 
 liquid diet, will cure, in most cases, the esophagitis with erosions and 
 ulcerations that accompany stenotic conditions. In addition to this, local 
 apjilication of argyrol to ulcerations and to granulation surfaces will aid 
 in clearing uj) these lesions. The cicatricial nature of the stenosis then 
 becomes quite apparent. Cancerous stenosis is accompanied by infiltra- 
 tion and a distortion of the shape of the lumen of the esophagus, which. 
 even in the absence of open ulceration, is (|uite different from the thin 
 at times almost membranous cicatricial stenosis. Im])ermeable cicatri- 
 cial stenosis may seem hard, Ijut cancer rarely is impermeabie until late.
 
 DISEASES OF THE ESOPHAGUS. 529 
 
 and in cancer, there are usnally nrojecting fungations and edematous 
 polypoid masses, when the disease has reached a condition of severe 
 stenosis. Prior to this time, infiltration of the esophageal wall is quite 
 apparent to palpation with the tube and probe. Moreover, in cancer 
 there is more or less of fixation of the entire esophagus, which does not 
 yield readily laterally to manipulations of the tube. It is necessary, how- 
 ever, to remember that cancer may develop at the site of a cicatrix, as 
 evidenced by the following case : 
 
 Robert M., aged ~i8 years, applied for admission to the Western 
 Pennsylvania Hospital for difficulty in swallowing, which had persisted 
 with variations in degree since the healing of a l)ullct wound 20 years 
 before. Within the last few months, there had been a steady increase un- 
 til only liquids could go down. There was a depressed wound in the 
 neck on the right side, and a scar three inches in length on the left side 
 corresponding, according to the patient's statement, to the site of an oper- 
 ation to remove the bullet which had not emerged. The patient stated 
 that immediately following the injury, he had noticed no bleeding, but he 
 had vomited material like coffee grounds not long after. On passing the 
 esophagoscope, I found a pharyngeal pouch or diverticulum. The sub- 
 diverticular opening was in the usual location, anterior to the pouch. This 
 opening was large, admitting a 10 mm. esophagoscope for about 5 cm. 
 At this level, the esophagus deviated very markedly to the left, the walls 
 were tightly adherent and there was a stricture of oval outline with a flat 
 ulceration of about 1 cm. in diameter, just touching the right strictural 
 margin. 1 excised the edge of this ulcer, including a portion of the 
 stricture. Examination of this tissue by Joseph H. Barach, showed it to 
 be a squamous-celled epithelioma. 
 
 Remarks. It is quite clear from the foregoing history that a cicatri- 
 cial stricture existed for 18 or 1!) years, and that the cicatricial tissue be- 
 came the site of the implantation of the cancerous process. Whatever 
 may be our ideas concerning irritation as a factor in the development of 
 carcinoma, there can be no doubt that cicatricial tissue and chronic in- 
 flammatory conditions offer a favorable soil for the development of can- 
 cer. The develo])ment of a diverticulum from cicatricial stenosis is 
 worthy of note as a very rare observation. 
 
 In comi)ression sienosis of the eso|)hagus, the lumen does not taper 
 down to a point as in strictures, and the outline of the lumen is linear 
 and more or less cresccntic, from the bulging inward of one wall convexly 
 from one side (Fig. 7, Plate III, Bib. 2G9), though occasionally it is 
 seen as a flattening of the walls with a more or less straight long dia- 
 meter. L'nless the compression is from a very firm growth, a small 
 esophagoscope can usually be insinuated through the compression, and
 
 530 "OISKASKS OF THK ESOPHAGUS. 
 
 the mucosa below will be found to be normal. The mucosa above in 
 cases of severe compression, may show the signs of chronic esophagitis 
 which accompany stasis and maceration. Ordinarily, however, compres- 
 sions are characterized by normal mucosa, which is in marked contrast 
 to the thin white appearance of the strictural margin. Spasmodic stenoses 
 are characterized by a wrinkling of the esophageal lumen which throws 
 the membrane into folds, and the crevices between these folds taper down 
 to a vanishing point, as shown in Fig. 7, Plate III. Moreover, gentle 
 pressure continued for a time will cause the spasmodic stenosis to yield 
 and tlie esophagoscope w ill pass on through. The mucosa below is usual- 
 ly normal, while that above may be more or less altered by chronic 
 esophagitis ; but the diagnostic point is the opening up of the constricted 
 area to the full lumen as soon as the spasm yields to pressure. General 
 anesthesia may be used to overcome spasm, but this is rarely, if ever, 
 necessary for the skilled esophagoscopist. though until skill is acquired, 
 great caution is necessary in applying any pressure on the supposition 
 that a condition is spasmodic stenosis. 
 
 Treatment of cicatricial stenosis of the esophoAjns. In dealing with 
 the esophagus, it must always be remembered that it is one of the most 
 intolerant organs with which we have to deal surgically. Shock is out 
 of all proportion to the extent of the operation or of the lesion, as shown 
 in ordinary acute esophagitis from traumatism. I'herefore, we must not 
 undertake treatment without due preparation of the patient as regards 
 everything that concerns his strength and endurance. If the patient has 
 not already been gastrostomized, it is wise to keep a very close watch 
 on the state of his nutrition during any form of treatment. It is always 
 possible for local reaction to entirely shut up the esophagus, and the 
 patient will very quickly suffer. Procedures are so much simplified by 
 having the patient regularly fed through a gastrostomic tube and the 
 putting of the esophagus at rest is so beneficial that there should be no 
 hesitation in advising it in the worst cases. In most instances, however, 
 a lumen for lic|uids remains, ami with care in diet, gastrostomy will 
 rarely be necessary. The general preparation of the patient, as men- 
 tioned on a preceding page, should be carried out as a preliminary to any 
 operation or examination on the esophagus. In addition thereto, abso- 
 lute rest of the esophagus to reduce the esophagitis. is an essential oper- 
 ative preliminary. Absolutely nothing but water, milk, ice cream and 
 consomme should be allowed, and bismuth subnitrate with a little calomel 
 from time to time should be swallowed dry, in small doses at fret|uent in- 
 tervals. Patients in a state of water hunger make exceedingly bad 
 surgical subjects, and absolutely no attempt at endoscopy should be un- 
 dertaken until the patient has fully recovered from food and water 
 starvation as before mentioned.
 
 DISF.ASKS OP TIIK I-SOPIIAGUS. 531 
 
 The question arises: To what extent shall dilatation of a stricture 
 he carried out? This must be determined by the functional result. In 
 some cases it is necessary to produce a very large opening because of the 
 sacculation almost amounting to a diveiticulum above the stricture. In 
 one of the author's cases, this was so great that it pressed on the lumen 
 of the esophagus below the stricture and interfered with swallowing to 
 such an extent that it was necessarj- to bite out the spur with forceps so 
 as to obliterate the bottom of the sack. In this case, the stricture was in 
 the neck. It is questionable whether such a procedure would be justifi- 
 able in the thorax. In another case a valve-like fold overhanging the 
 lumen of the stricture required removal. In cases in which there is very 
 little sacculation, a relatively small opening will give an excellent func- 
 tional result, and if an opening of six or seven millimeters can be main- 
 tained, the patient will have no trouble functionally, if food is perfectly 
 masticated. Imperfectly masticated food of any kind, of course, be- 
 comes a foreign body. The author has had cases that would sw-allow all 
 kinds of food when properly masticated but their esophagus would be- 
 come occluded from the swallowing of the pulp of a grape containing the 
 seeds. A number of times when this has occurred, maceration and soft- 
 ening of the ]ju1i) of the grape has allowe<l the seeds to go through and 
 the stenosis to be relieved, but of course foods of this kind should not 
 be partaken of. In two other instances an orange seed lodged between 
 the upper and the lower stricture in a jjatient that for many months be- 
 fore hacl been having no trouble wliale\er with eating all kinds of food. 
 After the author removed the orange seed, no further trouble was ex- 
 perienced, though two years have now elaj)sed in one case, and a year in 
 the other, during which time the patients have been partaking of all 
 kinds of food thoroughly masticated. These cases show how small a 
 lumen may suffice. It may be said, then, tliat the degree of dilatation 
 should be determined altogether functionally. Having obtained good 
 useful swallowing, it is questionable in some cases whether it is wise to 
 persist in an attempt entirely to obliterate the stricture and restore full 
 lumen, which involves more risk to the patient than is involved in the 
 obtaining of a useful lumen. A good functional result is better de- 
 termined by a bismuth radiography or fluoroscopy than by the sensations 
 of the patient. The stomach should be empty of food ( it is never entirely 
 empty of secretion ) and the bowels should be freely emptied by an enema 
 before any ojierative jirocedure upon the esophagus. There is a disposi- 
 tion on the part of the profession to disregard this common preoperative 
 precaution in patients who have been unable to swallow any food for 
 several days. No anesthesia, general or local, is needed and as any form 
 of treatment has to be frequentlv repeated, all hirms of anesthesia are
 
 533 DISEASES OF THE ESOPHAGUS. 
 
 contraindicated. The problem is to determine the best method of get- 
 ting a start in the dilatation of strictures of exceedingly small lumen, say 
 one or two millimeters in diameter. There have been many dilators and 
 divulsors devised, most of which can only be used in stricture of such 
 large lumen (say six or seven mm.) that they do not urgently need 
 dilatation. Such instruments are of use in hiatal and abdominal esopha- 
 gismus, but cicatricial esophageal strictures of large lumen, or those in 
 which a good start has been obtained, are of easy management, and the 
 choice of methods is of little moment. Small almost impermeable stric- 
 tures on the contrary are extremely difficult to dilate in the first stages 
 of the work. Personally the author has found nothing equal to bougin- 
 age per tubam. 
 
 Bonginage per tubam. The author uses the double olive bougies 
 (Fig. 61, p. 108, Bib. 2G9 ) only in the most minute strictures and then 
 only to get a start. In almost all cases the start can be matle and the 
 treatment continued with the filiform bougie jiermanently mounted on 
 the steel stem (Fig. 53). Three or four successively larger sizes can 
 be used at one seance. The last and largest bougie that can be safely 
 inserted is left in for about twenty minutes, the esophagoscope being 
 withdrawn, if desired, after the bougie is placed. At the next treatment 
 about two days later the start can usually be made with a bougie one or 
 two sizes larger than the starting size at the previous treatment. Treat- 
 ments are continued at intervals of a few days until the largest size that 
 can be inserted through the esophagoscope can be inserted and with- 
 drawn without resistance. The patient is then ready for the daily swal- 
 lowing of a common bougie of the old type. Under no circumstances 
 should he push it. It should be precedetl by the swallowing of about 10 
 cc. of olive oil for lubrication. After three or fourth months the interval 
 may be lengthened to a week or two, liut must not be abandoned for a 
 year. Even then a monthly passage is advisable for the early detection 
 of any tendency to recurrence. In children the size must be increased 
 from year to year proportionate to the normal esophageal growth and 
 development. The foregoing is the author's method in all cases where 
 the stricture is single and also in all cases of multiple stricture in which 
 the lumina of the lower strictures are concentric with the upper one. 
 The most difficult cases to treat are those in which there are many 
 strictures, and especially where the lumen of the stricture is not con- 
 centric nor in line with each other. In addition, there may be more or less 
 sacculation between the strictures rendering it extremely difficult to find 
 the aperture of the strictures below the first as shown in Fig. 41S. The 
 author's method of dealing with these strictures is to dilate first the 
 upper one forcibly and widely, then take the second one which now
 
 DISEASES OF THE ESOPHAGUS. 
 
 533 
 
 comes into view because a small tulie can be put through the first one, 
 which lias been dilated. l"or tliis jiurpose none of the divulsors to be had 
 are of any use. They do not stretch at the very end. so that thev must 
 be inserted far beyond the stricture to obtain any divulsion. Such inser- 
 tion is impossible in the most difficult class of cases with which we have 
 to deal : namely, multiple eccentric strictures, because the second stric- 
 ture will prevent the insertion of the instrument far enough to obtain 
 any divulsion on the first stricture. For this reason, the author has de- 
 
 FiG. 418. — Sclicniatic illustration of a series of eccentric strictures with in- 
 terstrictiiral sacculations, in the esophagus o£ a boy of four years. Divulscd 
 seriatim from above downward with the divulsor (Fig. 52), the esophageal wall, 
 D, being moved sidewise to the dotted line bj- means of a small esophagoscopc in- 
 serted through the upper stricture, A, after divulsion of the latter. 
 
 vised the divulsor shown in Fig. .")'2. With this instrument, we can di- 
 vulse the first stricture, e\en though it be less than 1 cm. away from the 
 second stricture. This is a safe i>rocedurc. because between the two 
 strictures there is always more or less of a pouch, in using the word 
 "safe,"' the author, nf course, means relatively safe, because any eso- 
 phageal instrument must be used with care and tactile appreciation of 
 the exact amount of force applied. 
 
 Since the stagnation of food is the greatest factor in the production 
 of esophagitis in these cases, it is necessary that the diet shall be care-
 
 534 
 
 DISEASES OF THE ESOPHAGUS. 
 
 fully regulated. Food should be taken in minute quantities at a time, 
 allowing a long time for a meal to be ingested. Liquid foods only are 
 to be permitted in certain cases. In other cases, and later on in all 
 cases, solids may be used, provided they be thoroughly masticated. Semi- 
 solids, and especially very soft boiled eggs, custards and the like usually 
 go down about as well as liquids, even in small strictures. The patient 
 
 ¥p 
 
 ^^r '^ ^m 
 ^^^H^^** ''' ^ 
 
 "' ^il^^^^l 
 
 1^ 
 
 k 'J 
 
 Hi 
 
 Fig. 4ig. — Radiograpli showing cnmjilctf cure ot a cicatricial stenosis. The 
 bismuth mixed with bread and milk went through into the stomach so promptly 
 and completely as not to show in this radiograph made immediately after taking 
 the mixture. The gastrostomy tube shown in the radiograph was immediately 
 abandoned. (Radiograph made by Dr. George \V. Grier. Author's case.) 
 
 must be instrucied that should any accumulation of food be felt it nuist 
 be regurgitated and followed by a glassful of a weak solution of sodium 
 bicarbonate. If this sodium bicarbonate does not go through promptly, 
 it should be regurgitated also, thus accomplishing a lavage of the 
 esophageal mucosa. Ice cream is a very valuable food in all forms of 
 stenosis and in all stages of after-treatment, not only because of the cold, 
 but because it is always ingested slowly. Of course there is nothing to 
 prevent a patieiU taking any liquid food slowly by the teaspoonful, but as
 
 DISEASIvS or TIIIC KSOr MAGUS. 
 
 535 
 
 a matter of fact, once tb.e patient gets away from the hospital it is ex- 
 ceedingly diflicult to enforce the rule of teaspoonful taking of fluids. 
 
 Numerous cases illustrative of the success of this treatment could 
 be cited, but a few will suffice : 
 
 A hoy of three years, consulted Dr. E. L. Jones of Cumberland, for 
 inability to swallow even water or saliva for eight days. The child 
 had swallowed lye eight months previously, and the inability to swallow- 
 had come on gradually. Dr. Jones immediately referred the case to the 
 
 Frc;. ^2C.— I-'rnm photugraplis of a 1ju\ of Imir Ncar.-i. \\ ci^lu wIk-u first seen 
 26 pounds. After jStli endoscopic bouginage, 42 pounds. Patient referred by Dr. 
 H. T. Price. 
 
 author. The child was in cvtrciiiis and its life was saved only liy a 
 prompt and skilful gastrostomy by Dr. James W. .Macl'"arlane. One 
 week later the author passed an esophagoscope and found at the 
 crico]iharyngeus a tight stricture ( 1 mm. ) which was divulscd with the 
 divulsor. Fig. ."i'.'. .\ second eccentric stricture about 1 cm. lower down 
 was similarly di\ulsed and bouginage per tubam com])lete(l the cure. 
 Six seances were reciuired to restore normal swallowing (Fig. 419). 
 The gastrostomy tube was abandoned. Xo anesthesia was used for the 
 treatment. The child now, otie year later, is ,ible iirom|>tI\- to swallow 
 any normally mastic.ilcd food.
 
 536 
 
 DISEASES OF THE ESOPHAGUS. 
 
 Remarks. The statement of the parents that tlie child had swallowed 
 no water for eight days is probably inaccurate. Some little fluid must 
 have leaked through the stricture or the child could not have survived. 
 
 A girl of two years was referred to the author by Dr. Abraham of 
 New York City for inability to s^vallow which came on a few weeks 
 after swallowing a solution of a washing powder. A general surgeon 
 failed to pass a bougie under chloroform anesthesia. Esophagoscopy by the 
 author revealed a tight stricture (1 mm. diameter) at about the crossing 
 of the left bronchus. A double olive bougie could be felt to engage in 
 
 Fig. 421. — Same patient as in Kiy. 420. Two years later. 
 
 two Strictures below, making three strictures in all. Bouginage per tubam 
 in about fourteen treatments cured the child completely. She swallows 
 food the same as any child. Now, five years later (seven years of age) 
 she can swallow a silk-woven bougie, 12 mm. diameter, without the 
 slightest check to indicate where the stenosis had been. 
 
 A boy, four years of age, was referred by Dr. H. T. Price for in- 
 ability to swallow. Immediate gastrostomy by Dr. R. E. Brenneman 
 saved the child's life. Esophagoscopy by the author revealed a stricture 
 J mm. in diameter. The smallest double olive bougie would jjass through 
 but was stopped by occlusion below. Bending the stem between the two 
 olives, enabled the author by rotation to find the lumen of the stricture
 
 DISEASES OK THE ESOPHAGUS. 537 
 
 below, wlicii a third obstruction was found (Schema l'"ig. 418). All 
 three eccentric strictures were treated by the author's method before 
 described, resulting in an ultimate cure. (Figs. 4"20 and 421). 
 
 Having described tlie method by which the author has been able to 
 restore normal swallowing to almost every patient with a permeable 
 eso[)hagus, some other esophagoscopic methods may be described. Blind 
 methods are not within the scope of this book. 
 
 Internal esophagotomy is, in the opinion of Killian and of the au- 
 thor, an extremely dangerous procedure. If justifiable at all it is only 
 so in the hands of the most experienced and skillful esophagoscopists. It 
 is necessary ocularly to recognize and cut cicatricial tissue only, never 
 the normal esophageal wall. This recognition is not always easy and may 
 be impossible. Personally, the author does not use internal esophagotomy 
 because he deems theoretically that dilatation subsecjuent to incision would 
 be very apt to result in a tear taking its start from the incision. In the 
 absence of an incision forcible dilatation carried out with reasonable 
 care and esjjecially with an acute tactile sense, need never tear cicatricial 
 tissue. The author used, endoscopically, in a number of cases (Bib. 257) 
 the string-cutting esopbagotome, Fig. 51, without mortality or serious 
 symptoms, but the abo\e outlined methods are so satisfactory as to leave 
 little to be desired. The author's esopbagotome (Fig. 51) can be turned 
 so that the cutting by the to-and-fro motion of the string will be only 
 on the manifest cicatricial part of the stricture. Guisez (Bib. 178) re- 
 ports excellent results from internal esophagotomy. 
 
 Electrolysis has yielded excellent results in the hands of (luisez ( Bib. 
 178). 
 
 String s7callozvin<j. So far the author has never yet encounlercil a 
 case in which he could not esophagoscopically find the lumen in any 
 stenotic case that had a lumen. If the lumen could not be found, doubt- 
 less the string swallowing method of Sippey could be adapted to esoph- 
 agoscopic use, the esophagoscope being threaded over the proximal end 
 of the string, the distal end having been swallowed some days before. 
 
 Retrograde esopliagoscopy. The first step is to get rid of the gas- 
 tric secretions. There is always fluid in the stomach, and this keeps 
 pouring out of the tube in a steady stream. Fold after fold is emptied 
 of fluid. Once the stomach is empty, the search begins for the cardial 
 0[)ening. When it is desired to do a retrograde esophagoscopv and the 
 gastrostomy is done for this special [)urpose, it is wise to have it very 
 high. Once the cardia is located and the eso])hagus entered, the remain- 
 der of the work is very easy. Piouginage can be carried out from below 
 the same as from above. It has been claimed that bouginage from below
 
 538 DLSICASES OF TlliC KSOPHAGUS. 
 
 is easier because there is never any dilatation below the stricture to con- 
 tend with, and strictures are much more apt to be concentric as ap- 
 proached from below because there has been no distortion by pressure 
 dilatation due to stagnation of the food operating through a long period 
 of time. This does not coincide with the experience of the author, who 
 has found peroral treatment of cicatricial stenosis easier and much more 
 satisfactory in every way. 
 
 Impermeable strictures may be classified under three heads. 
 
 1. Strictures of the cervical esophagus. 
 
 2. Strictures of the middle third. 
 
 3. Strictures of the lower third. 
 
 The cervical strictures are readily amenable to external esophagot- 
 omy with a ]ilastic operation for the opening up and reformation of the 
 eso]iliagus. The esophagus can be built up if necessarv out of skin flap 
 turned inward provided such flap can be procured from a location free 
 from hair. Such a flap must, of course, be turned in without severing 
 its attachment totally from the skin and rather a broad pedicle will be re- 
 quired to make sure of the nutrition of the flap until it becomes anchored 
 in its new position and vitalized by a new blood supply. 
 
 Imiiermeable strictures of the middle third of the esophagus are not 
 amenable to treatment by any means at present known, and the patient 
 will have to be satisfied with a gastrostomy, unil transthoracic esophagot- 
 nmy has been fully developed. J. W. Murphy and Samuel Iglauer have 
 done an internal esophagotomy, the peroral esophagoscopist using the 
 transillumination of the light of the retrograde esophagoscopist as a guide 
 for incision. The patient in this instance did not survive, but success 
 seems possible. Esophagoplication as done by Willy Meyer and others 
 will ameliorate the patient's condition. 
 
 In ca.se of impermeable stricture of the lower third the patieiu can 
 be cured by an operation l)y the I5renneman method. The general sur- 
 geon makes a new opening into the stomach, above the gastrostomic open- 
 ing, and as high u[) as possible. The surgeon then inserts his finger into 
 the esophagus u]) to the point of stricture while the esophagoscopist, 
 working from above, inserts his esophagoscope down to the stricture. 
 Under these circumstances the surgeon can feel the end of the esophago- 
 scope with the finger and is reasonably safe in cutting through into the 
 lumen of the esophagoscope. A soft rubber stomach tube is then passed 
 down by the esophagoscopist, and seized by the surgeon from below or 
 vice versa. This stomach tube is left in situ for a few days and is re- 
 placed by attaching with stitches a freshly sterilized one to the old one, 
 which serves to pull the fresh one down iiUo place. Tulies must be used
 
 DISEASES OF THE ESOPHAGUS. 539 
 
 for ihrcu or four weeks or hunger until the inner surface of the divided 
 stricture is ei)itheHalize(l. Then bouginage per tiibam must be used to 
 maintain the opening. Jn the author's case of this kind a very promising 
 result failed of ultimate cure because of neglect of the patient to return 
 regularly for bouginage. The really difficult part, the esophagotomy done 
 by Dr. K. E. Crtnneman. was an unqualified success. 
 
 lutuhatiun of the csopluujus has been very successful in the hands 
 of Guisez, whose excellent soft rubber tube lor the purpose is illustrated 
 in connection with esophageal intubation. ( q. v. I Briinings uses a 
 urethral bougie passed with a stilette having a thread, on which travels 
 a nut, which thus makes an adjustable shoulder pre\enting the stilette 
 reaching the extreme end of the bougie. A hole is burned w'ith a hot 
 wire in the proximal end of the bougie for the insertion of a silk thread 
 for the withdrawal The bougies are allowed to remain in situ about an 
 hour.
 
 CHAPTER XXXIII. 
 
 Diseases of the Esophagus. Continued. 
 
 DlVEiJTICUI.UM OF THE EsOP MAGUS. 
 
 Diverticula have been classified, according to their supposed etiology, 
 into traction and pulsion diverticula. The traction variety is situated 
 usually within the thorax and is due to the adherence of cicatricial tis- 
 sue ; the pulsion diverticulum is situated in the neck but may extend to 
 the upper thoracic aperture. 
 
 Traction diverticiilitin of tJie csopluuius is a rare condition and still 
 more rare is its endoscopic discovery, because it usually causes no symp- 
 toms. 
 
 The etiolog}' of traction diverticula is very concisely stated by Arthur 
 Keith, as follows: "1. A localized adhesion of the esophagus to the sur- 
 rounding part, usually due to inflammation of one of the bronchial glands. 
 2. Traction of this adhesion which occurs during coughing, deep inspira- 
 tion and deglutition. In these acts the trachea and the esophagus move 
 independently and elongate the adhesion formed between them with the 
 result that traction diverticula of the esophagus are formed." 
 
 Traction diverticula are very much less likely to be discovered than 
 pulsion diverticula because thev are, as a rule, much less in depth and 
 constitute really a localized one-sided enlargement of the tube, scarcely 
 amounting to a true pouch. Unless the esophagoscope is kept moving 
 laterally from one side to the other, they may easily escape discovery in 
 the folds of mucosa, unless a ver}- large esophagoscope be used, so as to 
 dilate the esophagus nearlv to a full normal lumen. Once the diverticulum 
 is found, unlike in pulsion diverticulum, the sub-diverticular lumen is 
 easily found and followed, because it gapes on inspiration and it is not 
 slit-like, because there is not the same subjacent orbicular muscular con- 
 traction, nor is there resistance to movement of the esophagoscope in any 
 direction. In some instances lateral movements of the tube will discover
 
 DISEASKS OF THE ESOPHAGUS. 541 
 
 tliat the esophagus is adherent tn a peri-esophageal mass. The mucosal 
 appearances may be the same as in pulsion diverticulum. The author has 
 seen but one case which was as follows : 
 
 A man of 48 years was referred by Dr. MacCandless for choking 
 on swallowing, which symptom was of two months' duration. There was 
 profuse and foul expectoration. The left vocal cord was paralyzed, and 
 the left arytenoid was atrophied, bronchoscopy showed a mass of granu- 
 lation tissue in the left bronchus and a traction diverticulum in the 
 esophagus with a mass of granulation tissue on the border of an ulcer 
 through which air leaked into the esophagus when the patient coughed, 
 'i'lie divcrticidimi consisted of a pouch-like dilatation of the anterior wall 
 of the esophagus above the crossing of the left bronchus. There was no 
 stenosis below the diverticulum. No spasm was apparent at esophago- 
 scopy, and the esophagoscope of full adult size could be introduced all 
 the way to the stomach. A specimen of the granuloma was removed 
 through the esophagoscope. Milk was found bronchoscopically in the 
 l)ronchi after swallowing. The patient died of exhaustion three months 
 later at his lionic. Autopsy was not permitted. Evidently the symptoms 
 were produced by leakage of food into the bronchi. Examination of the 
 removed tissue by Dr. Ralph Duffy showed it to be tuberculous. There 
 is no available treatment for traction diverticula. Fortunately they rarely 
 require treatment, l)ecause they rarely pro<luce symptoms. 
 
 Pulsion I)i\i;rticulum of thi-; Esoi'iiagus. 
 
 i'ulsion diverticula of the esophagus are usually small and may not 
 Ije larger than 1 or 2 cubic cm. capacity. On the other hand, they may 
 be quite large and may bulge out the neck like a large and low goitre, 
 especially w lu-n lilled with food. See Fig. 42."). Tbcy may be centrally 
 located behind the cervical esophagus, l)ut usuallv their bulk is to one 
 side, more often the left side. 
 
 liliolof/x. I'ulsion diverticulum is essentially a hernial sac caused 
 by [iressure of the food bolus at a point where the wall is weakly sup- 
 ported, as will be understood from the schema. Fig. 422. The llrm con- 
 traction of the cricopharyngeus may be realized by tlie firmness with 
 which the cricoid cartilage is pulled backward against the vertebral 
 column, as is familiar to every csophagoscopist, and as shown graphically 
 in Fig. 42;'.. Zenker recognized the effect of pressure in the causation 
 of pulsion diverticulum, but it remained for Killian to demonstrate the 
 anatomically weak point in the support of the wall and the spasmodic 
 resistance ahead (jf the bolus. Congenital tliverticula have been reported. 
 It might be supposed th;it an esi)ecially weak wall might exist from birth
 
 0-12 msKASKs or run: epoptiacus. 
 
 were it not for the fact that the greatest of all predisposing factors seems 
 to be age. Pressure diverticula are never seen in young people, very 
 rarely before middle life. Possibly crude boluses from imperfect masti- 
 cation liy defective teeth may contribute, but considering the rarity of 
 diverticula and the general prevalence of imperfect mastication this 
 alone could not be causative. Sir Felix Semon reports a very interesting 
 case of diverticulum of the esophagus occurring in conjunction with a 
 cono-enitallv deformed larynx. Undoubtedly cicatricial stenosis, in fact. 
 
 Fig. 422. — Schema illustrative of the etiology of pressure diverticula. O, 
 oblique fibers of the cricopharyngeus attached to the thyroid cartilage, T. The 
 fundi form fibers, F, encircle the mouth of the esophagus. Between the two sets 
 of fibers is a gap in the support of the esophageal wall, through which the wall 
 herniates owing to the pressure of food propelled by the oblique fibers, O, ad- 
 vance of the bolus being resisted by spasmodic contraction of the orbicular 
 fibers, F. 
 
 any sort of stenosis below the level of the inferior constrictors, may, in 
 rare instances, contribute to the formation of a diverticulum. Some of 
 the author's cases of diverticulum have been somewhat cicatricial at the 
 sub-diverticular orifice. This, of course, in a long-standing case, might 
 easily have resulted from erosion and ulceration following the esopha- 
 gitis due to stagnation. Undoubtedly after a diverticulum has developed 
 to a certain degree there exists "a vicious circle," that is the food in 
 the pendulous portion presses on the sulxliverticular portion of the 
 esophagus and thus increases the difticully of swallowing, and conse-
 
 DISITASKS OF TIIK KSfilMI ACIS. 
 
 543 
 
 (liR-ntly increases stenosis, with consec|uent increased pressure upon the 
 I)oucli. I"rf)m excessive activity the ol)lii|uc fibers may hypertrophy. It 
 is thus clear that all that is needed is to get a start; later, even though 
 the causes which originally started the trouble should disappear, the 
 diverticulum will perjietuate itself and continue to increase in size. (Fig. 
 421 and i-ir,). 
 
 Proiinosis. L'ntreated pressure diverticula Ijecause of the above 
 mentioned "vicious circle" probably always increase steadily in size and 
 conse(|uently in distressing symptoms. This is shown in the two radio- 
 
 FiG. 423. — Bismuth radiograph illustrating normal swallowing. Tlie bismuth 
 mixture is seen in the pyriform sinuses, D, E. .\t A and C is seen the bismuth 
 mixture in process of swallowing while the cricoid cartilage is in close contact 
 with the posterior pharyngoesophageal wall. 
 
 graphs of one of the author's patients who declined operation. (Figs. 
 ■I'^'l and A'2-)). The history of this case follows: 
 
 Male, aged 4() years, referred to the author by Dr. T. \). Uavis. 
 Patient stated that trouble in swallowing and spitting u[) of food began 
 suddenly after he "felt something give way" during a violent attack of 
 coughing. Cough had persisted since. Loss of weight six pounds. 
 Esophagoscopy showed a small pouch extending outward slightlv to the 
 left. The cricopharyngeal fold was quite aciUch- in flanimator\- anil the 
 pouch showed chronic esophagitis. The subdixerticular opening was a 
 narrow slit. It admitted a 7 mm. esojihagoscope readily, but the adult 
 size (111 mm. I lilted \er\- ti^btlv. Chronic larvngitis was manifest but
 
 544 
 
 DISEASES OF THE ESOPHAGUS. 
 
 laryngeal motility was normal. The patient declined operation. Four 
 years later he was found under the care of Dr. Marks. Operation and 
 esophagoscopy were both declined by the patient, but Dr. Marks very 
 kindly had the radiograph, Fig. 425, made by Dr. George C. Johnston. 
 The prognosis of radical operation will depend partly upon the condition 
 of the patient. If feeble from malnutrition and advanced age the prog- 
 nosis is more grave than in a vigorous person of middle age. Stettin 
 collected statistics of sixty radically operated cases with ten deaths (in.G 
 
 1 
 
 H 
 
 
 "1 
 
 J 
 
 Hi 
 
 ^^I^^^^^Bl 
 
 
 ifl 
 
 f "^ 
 
 
 HJ^ 
 
 Hj 
 
 i« 
 
 -- ^^^^ 
 
 1 
 
 Iwl 
 
 l^y-'^h : 
 
 
 ^1 
 
 m 
 
 L. 
 
 i^ 
 ^m 
 
 ^i^^^^l 
 
 Fig. 424, — Pulsion diverticulum filled with bismuth mixture in a man aged 
 46 years. (Radiographed by Dr. Russell H. Boggs. Author's case.) 
 
 per cent). As the duration of the operation is lessened by one-half by 
 cso]ihagoscopic aid, the mortality in the future will be diminished, especi- 
 ally in the aged and feeble. 
 
 Symptoms. The chief symptoms are cough, regurgitation of food, 
 gurgling sound and subjective sensation on swallowing, a peculiar sour 
 odor to the breath, and difficulty of swallowing. Boyce's sign can usual- 
 ly be elicited immediately after swallowing. It consists in a gurgling 
 sound produced by pressure of the hand on the side of the neck. A fresh 
 swallowing movement without food or water is needed for each test.
 
 DISEASES OF THE ESOPHAGUS. 
 
 545 
 
 The sound is probabl)' made by forcing out of air and bubbles of secre- 
 tion from the sac. All symptoms are valueless diagnostically but they 
 are urgent indications for esophagoscopy. 
 
 Diagnosis. A radiograph is very valuable and should always be 
 made, but to rely upon it to the exclusion of esophagoscopy is to take 
 a chance of serious or fatal error as mentioned in connection with spas- 
 modic and organic stenoses and malignancy. (See also Fig. 41o.) 
 X'arious ijlind methods have been brought forward, with a great deal of 
 
 Fig. 4J5. — Sana- patiuiit as in Fig. .4.^4, four >Lar> laKi, llit- patient having de- 
 clined operation. The great increase in size is usual in untreated cases. (Radio- 
 .ttraph made by Ilr. George C. Johnston. Author's case.) 
 
 enthusiasm, for the diagnosis of esophageal (li\ crliculuni. They are very 
 ingenious and would be perfectly justifiable in the days when esophago- 
 sco])y was crude or unavailable. It is hard to eradicate traditions in 
 medicine, and te.xt books are still being published stating that the tirsi 
 step i.i the diagnosis of diverticulum is to pass a sound; and then fol- 
 low^ descriptions of various other blind methods in groping for a fre- 
 quently erroneous diagnosis. These are all wrong. They annoy the 
 liaticnt and ;ire inconclusixe. The puiili>lied statement of one surgeon 
 that he made an erroneous diagnosis of carcinnm;i of tiie esophagus and
 
 546 
 
 DISEASES OF THE ESOPHAGUS. 
 
 did a gastrostomy in a case of diverticulum in wliicli he "decided to dis- 
 pense with the esophagoscope because lie (Hd not wish to subject the 
 patient to the risk and great annoyance" leads one to suppose that the 
 surgeon did not have available the services of a skilled esophagoscopist, 
 or possibly he had only seen the crude work of the earlv davs. There is 
 neither risk nor great annoyance connected with modern esophagoscopv. 
 The first step in the diagnosis should be a radiograph and the next step 
 should be esophagoscopy. The diagnosis will then be made positively 
 or negatively with a certainty that will render further diagnostic pro- 
 cedures superfluous. As a large quantity of bismuth is required for 
 
 ^ 
 
 Fig. 426. — The author's esophagoscope with slanted end, facilitating introduc- 
 tion in any case and especially useful in entering the subdiverticular opening in 
 cases of diverticulum. The drainage canal facilitates aspiration of secretions 
 without interruption of the work. Though similar to the bronchoscope, this esoph- 
 agoscope differs in having no lateral openings, and in the liranch tube entering 
 an auxiliary drainage canal ending at the tube mouth, like the regular esophago- 
 scope which it has superseded. The lip is also useful in foreign body work. 
 
 radiography of a large diverticulum or in the case of dilatation bismuth 
 subcarbonate should always be used rather than the subnitrate. Zir- 
 conium oxide, though somewhat expensive, is strictly non poisonous. 
 As pointed out by Kahler. if there is reason to suspect a tracheoesopha- 
 geal fistula the swallowing of bismuch emulsion had better be avoided. 
 In one such case a radiographic picture was obtained of the entire 
 tracheobronchial tree filled with liismuth which had found its wav in 
 through such a fistula. Malignant, sjiasmodic. cicatricial and compres- 
 sive stenoses are to be excluded by the esojihagoscojiic ai)])earances 
 Aneurysm is to be excluded by radiography and fluoroscoi)y. 
 
 Esophagoscopy in cases of suspected dkuvticuluiii. L'ntil a num- 
 ber'of cases have been exjjlored the esophagoscopist will find some difh-
 
 DISKASES 01' THK ESOCIIACIS. 
 
 547 
 
 cull}' in Ideating the siili(livi.Tticf:lar esophageal ojiening. The insertion 
 of the tube into the pouch is usually very easy. Its running into a blind 
 end or sort of pocket beyond which it will not go. and in the bottom of 
 which there is no opening, is almost diagnostic of pressure diverticulum. 
 If in addition to this on withdrawing the esophagoscope a little distance, 
 we are able to find on the anterior wall, a narrow'ed. usuallv slit-like 
 opening into the lower esophagus, and we are able to enter this opening 
 with either a very small tube or a jirobe. which passes down readily, 
 the diagnosis is absolute. The author uses the slanted-end esophago- 
 scope (Fig. I2<i) to enter this slit and exjjlore the subdivertieular esoph- 
 agus. True malignancy may exist below, and this the author has seen 
 
 Fu.. 4->7. — Esuphagoscopic \icws in cases of ilivertii'uluin. I'atient rccuiiibciU. 
 .-\, endoscopic view of linear suture after amptitaticni of tlu' divcrticiihim. P>, 
 after suture by li;jation and Iransfixation in another case, (.'rayon drawings by 
 the author, after operation by Dr. Otto C. Gaub. C, view looking into pouch 
 after partial withdrawal of the esophagoscope in a man aged 6- years. .Slit-like 
 f)rifiee of subdivertieular esophagus seen in upper right quadrant. 1), view of 
 diverticular nrilice in case of a woman of 58 years of age. Subdivertieular orifice 
 overhung by a fold in upper left quadrant. The ledge between the orifice and the 
 diverticular opening, supported by the orbicular fibers of the cricopharyngeus, is 
 cicatricial. 
 
 in one case, though, m liis opniion, the <le\elopmenl of nialignanev was 
 secondary to the di\erticulum ;inil to the subse(|ui'nt pathologic changes; 
 because (jrdinarily malignancy does not last sutliciently long for a divertic- 
 ulum to dcvclo]) from malignant stenosis. It is quite characteristic of 
 high (li\-ertietil;i due to pressure th;it the pouch seems to be the continu- 
 ation of the pharynx, and it is only with the most minute care and skill- 
 ful work that the subdi\ertictilar ojiening can be found, (lireat care must 
 be used not to jierforate the bottom of the pouch and not to tise an\- pres- 
 sure upon it. \\ hen the esophagoscopist tinds that the lube has entered 
 a blind c;i\ity ;ind cannot be introduced ftirther, he shottld withdraw the 
 ttilie while keeping :i close w.atcli on the aiUerior wall. Careful search 
 on this wall will dis-.-oxer .-m opening, somctiiues slit-like (C. 1), Fig.
 
 548 DISEASES OF THE ESOPHAGUS. 
 
 427) sometimes very small, rarely stellate, and very frequently over- 
 hung by a somewhat projecting fold. Some esophagoscopists have failed 
 to find the opening and have advised the swallowing of a thread with 
 which to guide the esophagoscope. Such an expedient is quite unneces- 
 sary though there is no objection to its use other than the delay and the 
 annoyance for twenty-four hours or longer when, instead, but a few 
 minutes of esophagoscopy should suffice. The subdiverticular opening 
 is apt to gape during swallowing. Therefore, it is often advantageous 
 to get the patient to make the swallowing movement if he can. This is 
 one of the advantages in making the examination without general 
 anesthesia. The best way of conducting these examinations is to use 
 the esophageal speculum Fig. 21, and after having discovered what 
 seems to be the cleft, to'insert a child's size of the esophagoscope with a 
 slanted end. Fig. 426, through the speculum. When it is certain that we 
 really have discovered the subdiverticular opening, the slanted-end esoph- 
 agoscope can usually be entered without difhculty and without the 
 speculum, provided there is no stricture. If there is a stricture, it should 
 be divulsed with one of the divulsors previously mentioned, or an adult 
 esophagoscope (Fig. 426) can be forced into it, using the slanted end 
 as an entering wedge. The square-ended esophagoscope, which is so 
 safe and popular for general use, is here at a disadvantage because of 
 the difticulty of insertion into the cleft-like orifice along the anterior 
 wall of the orifice of the diverticulum. One would suppose from the 
 name diverticulum, that in passing down the esophagus one would 
 notice a little side opening leading off into the pouch. This, however, is 
 far from the case. Usually in pharyngeal diverticulum, the whole hypo- 
 pharynx ends in a blind sac. The upper orifice of the diverticulum is 
 seemingly just simply the entire pharynx. The subdiverticular eso- 
 phageal opening, on the contrary', is a minute cleft up above the bottom 
 of the diverticulum, ami usually on the anterior wall of the diverticulum, 
 often close against the cricoid cartilage. The ledge between the orifice 
 of the diverticulum and the subdiverticular orifice of the esophagus is 
 supported by the orbicular fibers of the cricopharyngeus (often hyper- 
 troi)hicdi, whose contraction ahead of the downward propelled bolus 
 has been the ])rime factor in the production of the hernia known as 
 diverticulum. It is not so much this ledge that interferes with exposing 
 the subdiverticular orifice as it is the pressure of the cricoid cartilage 
 which pushes the esophagoscope backward and outward into the large 
 and unobstructed diverticular orifice. It requires firm anterior pressure 
 with the tube mouth to expose any orifice of the subdiverticular lumen 
 and then it will be found to he the merest slit and not a gaping orifice.
 
 DISEASES OF TUIC l"Si )!' II ACUS. 
 
 549 
 
 In the very early stages of diverticulum, there is sometimes not a true 
 pouch. In such instances, the subdiverlicular opening is easy to find. 
 The color of the mucosa lining a diverticulum may be reddish or it may 
 be macerated with a grayish color almost resembling an exudate. That 
 it is not a true exudate is manifest by the impossibility of removing it, 
 and it seems to be simjjly macerated epithelial cells furred up but not 
 detached. In other cases the diverticulum is rather paler than usual 
 and there being no pasty exudate on the surface, minute vessels are 
 plainlv visible in everv direction. There may be superficial erosions 
 and patches of inflammation. Cicatrices were noted by the author in one 
 case. The depth of a pulsion ili\erticulum may be from one to ten 
 
 Fit;. 428. — Bi'ginnini; recurrence of esophageal ilivcrticuhim in a man aged 5.i 
 years, witliin a year after removal by a very skillful surgeon. 
 
 centimeters, though usually they are not over 1 centimeters in deiilh, as 
 determined esophagoscopicall) , which nuaus in a more or less collapsed 
 state. When full of food, they are, of course, dilated to a very much 
 greater extent. In one of the author's cases the diverticulum filled with 
 air every time the patient swallowed without food or drink. Its normal 
 state seemed to be air dilatation. The same con<lition was suspected in 
 other cases but not proven. 
 
 Recurrence of esophageal dh crticidiim after operation. I'ulsiou 
 diverticulum has been known to recur after thorough removal by the 
 most skilful surgeons; and surgeons who have no record of recurrences 
 possibly have not had ojjportunities of following their cases. In a case 
 esophagoscoped for the exclusion of malignancy hy llie .lUlhor in con-
 
 550 DISEASES OF THE ESOPHAGUS. 
 
 sultation with Dr. George \\'. Crile and Dr. George E. I'.rewer there 
 was a large diverticukim which had formed during the twelve years fol- 
 lowing a resection of the first diverticulum by Dr. .Morris Richardson, 
 whose operation was, of course, thorough and complete, and had given 
 perfect relief for years. The recurrence brought back all of the old 
 svmptoms. The patient recovered absolutely normal swallowing after a 
 verv skilful operation by Dr. Crile, and now, at the end of four years. 
 is swallowing normally without signs of recurrence. 
 
 Recurrences are doubtless due to the same causes as produced the 
 original diverticulum. The author has thought that, as the original cause 
 is the weak point in the support of the esophageal wall, a leakage after 
 operation, with conse(|uent localized inflammation, far from being un- 
 desirable, might Ije a great advantage in bulwarking the weakly supported 
 area of the wall, which is necessarily right at the point of amputation 
 of the sac. As yet, the number of cases that have been followed have 
 been too small to yield any data. One case observed by the author tends 
 to confirm this theoretical conclusion. Figure 428 shows a beginning 
 recurrence within a year after thorough removal by a very skilful 
 surgeon. There was no leakage after the operation. 
 
 Treatment of pulsion diverticulum. Xo endoscopic treatment is of 
 any avail in esophageal diverticulum, so far as the removal of redundancy 
 is concerned. If the diverticulum is very small, the lower opening may 
 be freely dilated. This accomplished a cure in one case of the author, 
 but the diverticulum was \ery small. There was no organic stricture, 
 only spastic stenosis In another case the subdiverticular orifice was 
 small and cicatricial. Divulsion resulted in relief of the svmptoms, liut 
 the diverticulum remained. Both cases had refused external operation. 
 W hen there 's an\- degree of redundancy present, in the author's opinion, 
 it is very much better to have an external operation done by the gen- 
 eral surgeon. The author has devised an operation where, by the use 
 of the esophageal speculum. Fig. 21, the bottom of the sac mav be 
 grasped by forceps and drawn in. encircled by a ligature and the end cut 
 off and sealed over with a touch of tincture of iodine, about half strength. 
 As yet no suitable case for this operation has come under the author's 
 observation. Glottic spasm resulted every time traction was made, in the 
 two cases tested. In the event of radical operation being contra- 
 indicated because of advanced age or of organic disease present in 
 quite a proportion of cases, the best palliative treatment is to keep down 
 the chronic inflammatory state by preventing the entrance of food, or 
 by evacuating and cleansing the sac. The best method of doing this is 
 that of Starck as follows:
 
 DISI'ASI-S OI- TJin KSOIMlACrS. 
 
 •ll 
 
 ■■'I'lio aim .-liDulil lie to prevonl food from Ljfttiny into the diverti- 
 culum, and, if it does, to clear it out. Tiiis can sometimes be accom- 
 plished by reclining in a certain position, by stooping over or by jiressure 
 on the throat from without or other maneuver. This should be studied 
 until some measure is found which will relieve. If nothing of the kind 
 can be discovered, then the diverticulum tube must be used. It may be 
 nccessarv during the meal, as the filling of the diverticulum mav com- 
 
 Fic. ^2g. — .Scluiiialic rcpreseiitatici! of csoplia^oscopic aid in tlu' excision of 
 a diverticulum. At .\ the es.ophagoscope is represented in the hottom of the 
 pouch, after the surgeon has cut down to where he can feel the csophagoscope. 
 Then the csophagoscopist causes the pouch to protrude as shown by the dotted 
 line al F^,. .After the surgeon lias dissected the sack entirely loose from its sur- 
 roun(lin;,'s, traction is made upon the sack as shown at H and the csophagoscope is 
 inserted down the lumen of tlie csopl'.agus as shown at C. The csophagoscope 
 now occupies the lumen which the patient will need for swallowing. It only re- 
 mains for the surgeon to remove the redimdaucy, without risk of removing any 
 of the normal wall. 
 
 press the esophagus so that its lumen is olistructed ; in any e\eni tlic 
 toilet of the (li\erticiilum should follow the meal. .Xearlv ever\' patient 
 has his own method of eating to i)revenl annoyance from the food get- 
 ting into the cli\t-rticnlum ; oik- can swallow bclU-r when he looks at the 
 ceiling, another when he bends his head to the right or left, another as 
 he stoops his body forward, or ])resses "U the tr.aclu'a from the front 
 or the side or from behii'd ihe sternocleidomastoid muscle. Xeukirch
 
 553 DISEASES OF THE ESOPHAGUS. 
 
 had a patient who could swallow best when he reclined, lying on his 
 right side. The various postures should be tried until the one giving 
 the most relief is discovered." 
 
 The excision of a diverticulum in the neck, one would suppose from 
 the description in the text hooks to be an exceedingly easy procedure, and 
 so it may be in the case of a large diverticulum in an emaciated long- 
 necked person. On the contrary with a short thick-necked individual and 
 a small diverticulum, it may be exceedingly difficult ; so much so that it 
 has happened to a number of very competent surgeons that after the 
 operation the diverticulum remained as before. If a diverticulum at oper- 
 ation were full of a solid as it is when the radiograph is taken, finding it 
 would be easy, but the sac is extremely elastic and when empty, as it 
 must be for operation, it shrinks up to small dimensions. It lies back of, 
 or close alongside the esophagus, and may be indistinguishable from a 
 fold of the esophageal wall, and it may be on the opposite side of the neck 
 at the time it is sought. Free dissection of the esophagus clear from all 
 surrounding structures and bringing it out for examination as one would 
 an intestine is, of course, impossible. All of these considerations render 
 the operation as ordinarily done a lengthy and a tedious one that is 
 quite an ordeai for old debilitated patients. The duration of the opera- 
 tion is lessened by a half or two- thirds and the difficulties for the sur- 
 geon are greatlv diminished if he have the cooperation of an esophagos- 
 copist as originally proposed by Dr. Otto C. Gaub. A description of 
 the esophagoscopist's part of Dr. Gaub's operation is all that is within 
 the province of this book. This will be fully understood by reference 
 to the schema. Fig. 429. In these operations it is, of course, absolutely 
 necessary that the surgeon have his sterile tables, nurses and assistants 
 entirely independent of the esophagoscopist who has his sterile organiza- 
 tion at the head of the table with the anesthetist. Two cases in which 
 the author thus assisted Dr. Gaub may be cited. 
 
 Airs. D., aged 58 years, referred by Dr. R. W. Fisher, for increasing 
 difficulty in swallowing solids. Foul breath and a cough were annoying 
 at times. Had "ulcerated sore throat" four years before. Swallowing 
 symptoms were of one year's duration. No regurgitation. Examination 
 with the esophageal speculum (Fig. 21), without anesthesia, general or 
 local, showed a small diverticulum to the left side. Withdrawal re- 
 vealed the orifice of the subdiverticular esophagus anteriorly to the right 
 covered with a fold. The ridge between this orifice and the diverticular 
 orifice was cicatricial (D, Fig. 427). The subdiverticular orifice was 
 easily entered with the beak of the slanted-end esophagoscope (Fig 42G) 
 but would not permit the entire end to enter readily. Enough pressure 
 was used to stretch the cicatricially contracted orifice and permit the
 
 DISEASES OF TUU E^OPllAGLS. 
 
 553 
 
 esophagoscope to enter freely. At esophagoscopy, seventeen days later, 
 without anesthesia, the esophagoscope entered readily without any sign 
 of recurrence of stenosis. Radiography by Dr. George C. Johnston 
 showed the diverticulum (Fig. 430). External operation was quickly 
 and skillfully done by the Otto C. Gaub method in which the esophagos- 
 copist with esophagoscope inserted through the mouth into the bottom 
 of the pouch presents the sac in the wound to the surgeon after the lat- 
 ter has dissected externally down to the esophagus (Fig. 429). After 
 
 Fig. 4,30. — Radiograpli li\ Hr. Gcorgt- C. Johnston showing divorticnhnn in 
 case of a woman, aged 58 years. Uivcrticnlnni rifterwanls rcmcjvcd by the OUo C. 
 Gaulj method. 
 
 Dr. Gaul) had laid bare the esophagus by external dissection he asked 
 the author to insert the esophagoscope and present the pouch in the 
 wound. When Dr. Gaub had seized the bottom of the sac with forceps 
 and made traction the esophagoscope was withdrawn to the hypopharynx 
 and the orifice of the diverticulum disappeared while the subdiverticular 
 orifice opened up ahead of the tube-mouth in full lumen. Inserting the 
 esophagoscope in this lumen as far as the crossing of the left bronchus 
 the surgeon amjiutatcd the redundancy while the esophagoscope indi- 
 cated the normal liunen. The neck of the sac was ligated and transfixed.
 
 554 
 
 niSKASI'S OF THE ESOPHAGUS. 
 
 When the esophagoscope was withdrawn a neat puckered spot of suture 
 was seen by the author who made the sketch, B, Fig. 4'27. The stump 
 externally was lightlv touched with pure carbolic acid, and supporting 
 sutures were used. Feeding was by catheter inserted at esophagoscopy. 
 Primary union and prompt recovery followed, and one year later the 
 patient was still swallowing perfectly. 
 
 Remarks. In this case Dr. (laub made traction on the bottom of 
 the sac with forceps and the author withdrew his esophagoscope to the 
 
 Fig. 431. — Radiograph by Dr. Pancoast of Philadelphia, showing a diverticulum 
 in a man of 6- years. Diverticulum removed by the Otto C. Gaub method. 
 
 h_\ popliar\n.\ and noted that the traction Ijv Dr. ("laub caused the sub- 
 diverticular esophagus to gape widely, bringing it into a straight line 
 with tile esophagus below. This manipulation demonstrated clearly that 
 the dilticulties in swallowing and in finding the subdixerticular orifice at 
 diagnostic esophagcscopy are largely concerned with the pouch and its 
 position, and not alone with tlie spasm of the orbicular fibers of the 
 cricopharyngeus. 
 
 Mr. F., aged (u years, was referred by Dr. r)a\id Riesman and Dr. 
 Walter J. Freeman of f'liiladelphia. The\- had made the diagnosis of
 
 UISICAsns Ol- I'lII-. ESUl'HAC.US. o')') 
 
 (livcriiculuni. Severe (.•nu^h, piinileiu expectoration aiul (litliciilty in 
 swallowing hail made the patient's life miserable for the past year. Re- 
 gurgitation and loul hreath had been noticed for six months. Examina- 
 tion with the esophageal speculum, using a little 8 percent cocaine solu- 
 tion tn tin- larvngo])harynx, showed a large pouch confirming the radio- 
 gra[)h by Dr. ilenry K. I'ancoast, J'ig. -I'il. The subdiverticular orifice 
 ( C, Fig. 427 ) was easily entered with the slanted-end esophagoscope, 
 Fig. •!?(>. There were no signs of cicatrices or inflammatory processes. 
 The orifice of the pouch just as the esophagoscope emerged from it was 
 circular in outline and rolled o\er at the margins ( C, Fig. 127). The 
 Gaub operation with esophagoscopic aid was done by Dr. Gaub. the 
 steps being the same as in the preceding case, and the same observation 
 
 Fii;. 4_3J. — Pulsion (livcrticuluni cf tlie esophagus removed from a man aged 
 ()- years, by Dr. Otto C. Ganb. 
 
 as to opening u|> of the subdiverticular esophageal lumen was made 
 as in the preceding case. The pouch after removal is .shown in iMg. 1 :>"■.'. 
 'i'lie recovery was rather tedious. Leakage of about one-third of swal- 
 liiucd li(|uiils gradually inii)roved as the fistula closed. Healing was 
 complete and swallowing perfect in about four weeks, the patient reliu-n- 
 ing to I'hil.-idelpiiia six weeks after operation. 
 
 J^riiHirks. 'j'his patient was regarded by Dr. j. .M . McKelvy before 
 ojieration as an unfavorable surgical subject because of feebleness, ad- 
 vanced age. impaired vessels, and chronic jiurulent bronchitis. The 
 post operative condition \erified the opiifion ; and it was onl\ b\ the at- 
 tentive after care of Dr. Gaub and Dr. McKelvy that the jiatient made 
 sucii an excellent recovery. Intratracheal insulllation anesthesia with 
 the Elsberg api>aratus was used in both the foregoing cases. The in- 
 sulllation method not only removes the anesthelist from liie (]|)er,-itor's
 
 556 DISEASES OF THE ESOPHAGUS. 
 
 way, and avoids infective risks, but also insures safety of respiration 
 and a quiet peaceful anesthesia, in spite of tracheal pressure from the 
 esophagoscope or glottic spasm from the surgeon's dissection. 
 
 After-care. As the primary cause of the diverticulum was high 
 pressure of swallowed food and drink held back by the spasm of the 
 orbicular fibers of the cricopharyngeus at the bottom of the hypopharynx, 
 naturally it follows that swallowing will put great strain on the stitches. 
 For this reason it is wise to place a feeding catheter of small size in the 
 esophagus at the time of operation, preferably through the esophageal 
 speculum. If put in afterward it may catch at the point of suture. 
 Should leakage start and the leakage through the neck wound be so 
 great that enough food and water do not reach the stomach, fluid food 
 can be carried safely past the wound by feeding through the catheter. 
 If this be done an abundance of sterile water must he drunk in addition 
 in order to flush out the wound. Usually by this time granulations af- 
 ford some protection against serious infection and the channels to the 
 mediastinum are sealed. The wotind, in case of leakage, is already in- 
 fected with the esophageal and buccal organisms, but to these the 
 patient is more or less immune. The water must be sterile to insure 
 exclusion of virulent infections from without. If offensive odor develops, 
 frequent irrigation by swallowing sterile water will quickly cause it to 
 disappear. j\Ir. Walter Howarth made the excellent suggestion, apropos 
 of the case of Mr. F., that hydrogen peroxid be added to the water. 
 In order to determine the amount of fluid that goes into the stomach, 
 the method of Dr. Otto C. Gaub is useful. When the patient swallows 
 water the leakage is caught in a curved pan held at the external wouml, 
 and the quantity is measured. Subtraction of this from the total (|uan- 
 tity swallowed necessarily gives the amount that went to the stomach. 
 As oral sepsis is one of the greatest dangers, cleanliness of the mouth 
 must be insured by brushing the teeth every few hours, and by the rins- 
 ing of the mouth with alcohol 1 part to 5 of water. After operation 
 it is wise for the surgeon to have a bismuth radiograph taken and to 
 have an esophagoscopy, both as a matter of record and to make sure that 
 even,-thing is anatomically as well as functionally normal in the esophagus.
 
 CHAPTER XXXIV. 
 
 Diseases of the Esophagus. Continued. 
 
 r.\KALYSIS OF Tllli ESOPHAGUS. 
 
 Paralysis of the csophui/iLs may be motor or sensory. — Motor 
 paralysis of the esophagus is perhaps more frequently seen as a 
 glosso-labio-pharyns^eal paralysis of either toxic origin as in diph- 
 theria, or of central origin. In any case, swallowing is apt to be seriously 
 interfered with, and, strange to say, esophageal drainage is interfered 
 with also. This is manifest by the filling of the pyriform sinuses with 
 secretion (author's sign of esophageal stenosis) until the secretion over- 
 flows into the larynx, just as in an esophagus occluded l)y cancer or 
 organic stricture. This is apjiarent on indirect as well as direct examina- 
 tion. It is a remarkable thing that though the normal esophagus can swal- 
 low "up hill" with ease, food, either li<|uid or solid, will not go down the 
 paralyzed esophagus Ijy gravity alone. The act of deglutition is a i)urely 
 muscular process and the food is forced down by coordinate muscular 
 activity. Xormally the esophagus empties itself promptly of everything 
 which is put into it. It abhors the presence of anything except secre- 
 tions, and even secretions are promptly gotten rid of in a state of health. 
 Phylogenctically, the erect posture was developed late, therefore, there 
 has been no opportunity for the develo])ment of deglutition with the 
 assistance of gravity. Muscular action is depended upon entirely. 
 Therefore, it is well to mention here again what was stated in the first 
 volume (Bib. 2ii9) : namely, that the first symi)tom of paralysis or paresis 
 of the esojihagus is inability to swallow. That paralysis of soisation 
 in the esoi)hagus may result in inaliility to swallow because of the lack 
 of tile necessary serial reflex impulse is proven Ijy the following case 
 refcTred to tlie author for esophagoscopy by Drs. li. V>. llowarth and 
 Kobert Milligan. A man of forty-eight years had difficulty in swallow- 
 ing for eight weeks, culminating in absolute inabilitv to swallow. On
 
 558 DISEASES OF Till-: ICSUI'MACUS. 
 
 indirect laryngoscopy laryngeal motility was found to be perfect. The 
 pyriform sinuses were full of secretion. A bronchoscope was passed to 
 the bifurcation of the trachea without anesthesia, general or local, and 
 there was not the slightest sign of a cough reflex. Esophagoscopy 
 showed ])resence of cricojiharyngeal and hiatal contractions, though very 
 weak and unlike normal spasmodic resistance to the achance of the 
 esophagoscope. A lo mm. x 5:i cm. esophagoscope passed readilv into 
 the stomach. There was no gagging, retching or attempted vomiting. 
 The author made a diagnosis of sensory paralysis, with consequent ab- 
 sence of the normal serial deglutitory reflex, and turned the case over 
 to Dr. C. C. Wholey for neurologic analysis and treatment. The follow- 
 ing is Dr. Wholey's report : 
 
 "Patient's mental condition is good, but he shows some anxiety re- 
 garding his condition. There is noticeable dilatation of the venules over 
 cheeks. E. J.'s (biceps i_ \\'. J.'s. and muscle tap (biceps) all plus and 
 eciual on both sides. K. J.'s (taken in bed) absen.t — also absent when 
 sitting. I'lantars lively. No Babinski. No Oppenheim, Tongue pro- 
 trudes slightly to the left. Eyes. Pupils — Rt. — i x 4, irregular (wider 
 below.) Lft. 3J/ X 3J,-2, irregular (wider above). Both inipils react 
 l)romptly to light with fair excursion; both react to accommodation. 
 Patient shows slight Rhombergism; is able to pucker lips and protrude 
 tongue. Abdominal reflex absent. Cremasteric present but slow in re- 
 sponse. Sensation : Patient's sensation to touch, heat and cold normal 
 over entire body, but sensation for pain is diminished from the hips 
 to soles of feet. Increasing analgesia as soles of feet are approached, 
 being very marked in soles of feet. For tlie last one and a half to two 
 years patient has complained of sensation of pins and needles in thighs, 
 of impairment of the sense of taste, of anorexia from time to time dur- 
 ing the past few month.s, and obstinate constipation (loss of sensation 
 in rectum). Desire has been present, but patient has been impotent 
 sexually during the past IJ,^ years. Patient says he has been unaware 
 of any desire to urinate or to defecate during the past month ; simply goes 
 mechanically. Patient coughs a great deal, brings up thick mucous, but 
 his expelling ])ower seemed to be largelv from the diaphragm and ab- 
 dominal muscles. Examination of urine is negative, except for the pres- 
 ence of a reducing agent present in small amount and found to be glu- 
 cose. No T. ]!. found in sputum, i'.lood picture is negative, except for 
 very slight leucocytosis. ^^■assermann negative. The spinal fluid shows 
 -"iK' lymi)hocytes per cmm. ("dobulin positive, ^\'assermann negative. 
 Radiographer after examination of lumbar region reports osteo-arthritis 
 of vertebrae. Radiograms of lumbar and cervical regions show numerous 
 small si)icules projecting from bodies, and lateral processes of vertebrae.
 
 DisKAsKs cj" rill-: i:sui'iiacus. .").".!) 
 
 During the week subsequent to above examination, patient had several 
 periods during which he developed Cheyne-Stokes respiration, and 
 seemed in imminent danger of dying. .Mercurial inunctions have been 
 gi\cii after above examination, and during the week subsequent to the 
 attacks, patient has become much better, coughing much less, respiration 
 easier and there is less ditiiculty in taking the stomach tube. Sensation 
 over thighs and legs more acute. .\rea about rectum and over buttocks 
 supi)lied by the sacral nerves remains without any sensation for pressure 
 or pain. Radiogram shows enteroliths in rectum. Diagnosis. The case 
 presents the characteristics of a disseminated myelitis, located mainly in 
 the lumbar and cervical regions It is apjiarentlv due to pressure and 
 irritation of the s])inal nerves and their root zones (especially sensory) 
 by bony inflammatory ]:)roducts, and to the same pressure upon the 
 medulla, aft'ecting the vagus noticeably after the union of its sensory 
 and motor bundles. It is possible tliat the same underh'ing cause has 
 brought about both the myelitis and the osteo-arthritis, and in view of 
 the fact of tlie patient's improving so noticeably since lieing upon mercur\', 
 I should regard syphilis as the causative agent. The affection is largely 
 sensory in character and the parallelism between the symptoms aft'ecting 
 the centers in the medulla (deglutition, coughing, respiration, etc.) and 
 those in the lumbar region (sacral segments), is very striking, it being 
 observable that oidy Miluntary activity is possible, such as starting the 
 act of deglutition or of micturition, but all those reflexes depending upon 
 sensory stimulation are either abolished or greatlv crippled." The fol- 
 lowing is an illustrative case of esophageal motor paralysis: 
 
 Xellie S., aged 21 years, referred by Dr. J. E. Gross for graduallx' 
 increasing difficulty in swallowing. Difticultv in s]5eech had lasted three 
 weeks. There was no nausea, no regurgitation of food, bin on attempt- 
 ing to swallow, choking and coughing ]iroiiiptly followed and the food 
 came back immediately. The patient had not lieen able to swallow liquid 
 for the last four days, and was in an extremeh- serious state of water 
 hunger. ( Jn examination, the nio\ement of the palate was defective, 
 but there was a slight movement of irregiUar character. Pus was 
 streaming down from the sinuses jiosteriorly. The pyriform sinuses 
 were full tf) overflowing with secretion. The movements of the tongue 
 were sluggish. iMiunciation was very imperfect and difficult to under- 
 stand. The patient was languid, extremely feeble and emaciated. Ksopb- 
 agoscopy caused no inconvenience after draining out all of the fluid 
 in tlie pharynx. The eso])hageal mucosa was exceedingK pale, and no 
 sign of cricopharyngeal contraction was apjiarent. The intra-thoraeic 
 portion was enlarged by the negative iiressure of inspiration ratlier more 
 tluui u>tial. Ili.tl.il I'ontraction was about normal for a feeble person re-
 
 oGO DISEASES OF THE ESOPHAGUS. 
 
 laxed by water hunger, and examined without anesthesia. Dr. W. K. 
 Walker, after a careful neurologic examination, reported as follows : 
 
 "The patient presents dysarthria and dysphagia, with paresis of the 
 muscles of the lips, tongue, palate and pharynx. Closure of the eyelids 
 is weakened. Though there is general weakness, it is not more than can 
 be accounted for by weeks of deprivation of nourishment and fluids, 
 through inability to swallow. There are no sensory disturbances ; hand- 
 grasp is of fair strength ; gait is normal. Deep reflexes of upper ex- 
 tremities are normal. Knee jerks, right and left, are absent. Respiration 
 is entirely costal and there is marked breathlessness and tachycardia 
 after esophageal tube feeding. There is no marked weakness of the jaw 
 muscles; neither is there involvement of the bladder or rectal muscles. 
 The mind is clear. Diagnosis : Myasthenia gravis or asthenic bulbar 
 palsy.'' The patient was given water and liquid food with a stomach 
 tube and gained slightly in weight, but died after about two months from 
 paralysis of respiration. Dr. Edward E. Meyer, the neurologist, under 
 whose care she was at this time, was unable to obtain an autopsy. 
 
 Endoscopic appearances of paralysis are characteristic if the paraly- 
 sis is complete. There is noted an absence of the spasmodic contraction, 
 which usually characterizes an esophagoscopy without anesthesia. This 
 is most noticeable at the cricoid. At the hiatus, no lessening is usually 
 noticed in the degree of contraction, probably because these contractions 
 are dependent largely on the diaphragmatic musculature, which mav not 
 be involved. The esophagus is apt to be quite flaccid and it is also 
 unusually insensitive to the introduction of the tube, even though the 
 paralysis be purely motor. If the patient has been able to take any food, 
 particles adherent to the esophageal wall may be noted. Their absence, 
 however, is not to be taken negatively. 
 
 Etiology. The causes of esophageal paralysis may be classed under 
 four heads. 1. The toxic type, such as diphtheritic paralysis. 2. 
 Purely functional paralysis, as in hysteria. 3. Peripheral paralysis as 
 from neuritis. 1. Central paralysis is usually from a bulbar lesion, as 
 in glosso-labio-])haryngeal paralysis. The latter condition may be luetic 
 as may also the neuritis. 
 
 Diagnosis. The most common diagnostic error is to mistake eso- 
 phageal paralysis for hysteria. When a patient is starving for food and 
 water and complains of inability to swallow and the esophagus is seen 
 on esophagoscopy without anesthesia to be free from spasm at the 
 cricopharyngeus. and is patulent to a large esophagoscope, the diagnosis 
 of hysteria must not be made until paralysis is excluded. Flaccidity 
 may readily be mistakenlv attributed to weakness from inanition. But if
 
 DISEASES OF THE ESOPHAGUS. 561 
 
 the possibiliU' of paralysis is ke[it in mind tlic total absence of the normal 
 spasmodic constriction at the cricopharyngeus when the esophagoscopc 
 is passed without anesthesia will be conclusive. I'aralysis of the esoph- 
 agus is practically always accompanied by other paralyses about the 
 upper air and food passages that are distinctive and easily recognized. 
 Difticulty of swallowing with a history of recent diphtheria should al- 
 ways bring esophageal paralysis to mind, and immediate esophagoscopy 
 should be done. In jjaralysis of esophageal sensation, the reflexes of 
 coughing, vomiturition and vomiting are absent or deficient at bronchos- 
 copy and esophagoscopy, and the muscular contraction of the crico- 
 pharyngeus is feeble or absent. 
 
 Treatment. There is no form of endoscopic treatment that is of 
 any use. Esophagoscopy is of value in determining whether or not there 
 is any lesion in the esophageal lumen that would contraindicate the pass- 
 ing of the feeding tube. If there is any lesion, such as sloughing or ero- 
 sion, gastrostomy should be done. In the absence of such lesions, which 
 are rare, the patient can be nourished effectually with milk put in through 
 the ordinary stomach tube. The treatment will then dei>end entirely 
 upon the internist and the neurologist. 
 
 LUKS OF THE ESOPH..\GUS. 
 
 Luetic disease of the esophagus is, relatively, a rare disease, though 
 it is not as rare as the standard literature on the subject would seem 
 to indicate, for two reasons. 1. Prior to the days of esO])hagoscopy, 
 but little was known of esophageal disease, except what happened to be 
 found at post mortem. 2. The esophagus is rarely explored at autopsy- 
 Prior to the days of esophagoscopy, a few diagnoses of luetic disease of 
 the esophagus were made solely upon the fact that difficulty in swallow- 
 ing disap])earcd upon the administration of specific treatment. Neces- 
 sarily, this leaves a large possibility of error. Such cases might be 
 si)asni or compression. The esophagoscopc, however, has demonstrated 
 that luetic disease of the esophagus may show itself either as a mucous 
 plaf|ue, a gumma, an ulcer, or a cicatrix. In llu- absence of associated 
 lesions, it is not jiossible to make the diagnosis on the esojjhagoscopic 
 appearances alone. They must be taken along with the history, the con- 
 comitant lesions, the thera])eutic test, the W'assermann test, the luetin test, 
 the examination of tissue and a search for spirochetes. In the cicatricial 
 form, the absence of any other cause for a cicatrix coming on late in 
 adult life, should arouse a strong suspicion of lues. \\'here there is 
 a history of ditticulty in swallowing in childhood, there is always a pos- 
 sibility that the swallowing of some caustic, or the traumatism of a for- 
 eign body may have been overlooked, and as suggested by .Mr. Tilley,
 
 562 DISKASI-S <)K TlIK KSOI'IIAGUS. 
 
 the possibility of the late manifestation of congenital stenoses must he 
 borne in mind. 
 
 Esophageal luetic stenosis, like the same condition following any 
 other form of ulceration, is very apt to give the history of difficulty of 
 swallowing, which improves as the ulcer heals and then comes on with 
 renewed severity as the scar contracts. 
 
 Bsopliayoscopic appearances. In considering the esophagoscopic ap- 
 pearances of lues, it is necessary to remember that the appearances in ul- 
 cerative stage.s are due largely to the mixed infection'; and the resultant 
 inflammatory condition. The same is true of tuberculosis and of cancer 
 when these have reached the ulcerative stage. The differential diagnosis 
 of the various ulcerati\-e lesions in the esophagus is considered under "L"i- 
 ceration of the Esophagus." The mucous platjue of the esophagus looks 
 quite similar to that seen in the fauces. It may be slightly elevated in one 
 part, and simply a bluish white cloudiness in another part. The lesion 
 is typically inflammatory in character. The cicatrix of luetic esophagitis 
 does not dift'er from other cicatrices. The esophagoscopic picture of a 
 scar which involves only a small portion of the ring of the esophagus, is 
 very apt to present a linear appearance on esophagoscopy for purely 
 mechanical reasons, inherent in the inspection of the interior of a col- 
 lapsed tube, which is explored by an endoscopic tube (see Fig. It. Plate 
 III). The gumma of the esophagus does not differ materially in appear- 
 ance from gumma seen anywhere else in the mucosa, except in so far as 
 it is an endoscopic instead of a right-angled view. The foregoing is a 
 brief description of the various lesions as seen by the author. Xo one 
 has seen a sufficient number of cases to be able to classify the endoscopic 
 pictures, and even though it were possible to do so, the diagnosis wotild 
 necessarily, here as elsewhere, rest upon the laboratory findings, the 
 therapeutic test and the concomitant lesions. 
 
 Treatment. The treatment of luetic esophagitis, as with the same 
 infection elsewhere, is altogether systemic and not local. One point, 
 however, is of great importance, and that is to prevent the cicatrices 
 from contracting after the healing of ulceration, should the esophagos- 
 copist be so fortunate as to encounter the case in the ulcerated stage. 
 Unfortunately, howe\er, he is much more apt to see it in the cicatricial 
 stage when the mechanical treatment required for cicatricial stenosis must 
 be instituted. In the stage immediately following the healing of the ulcer, 
 the scar can be prevented from contracting if a silk woven bougie is 
 passed every day, and left in situ for a half hour or longer. The bougin- 
 age should be done by the esophagoscopist himself under the direct guid- 
 ance of the eye. Once established, cicatrices of luetic origin are ex- 
 ceedingly stubborn to treat, and may re(|uire the string-cutting esophago-
 
 DISKASKS Ol" Tin: I'.SOPHACL'S. 563 
 
 tome or otlior loriii of internal esophagotomy. followi-d liy daily dilata- 
 tion. Comi)lcte cure, as in the case illustrated in Fii;. ll'>, will reward 
 l)atient. carefid work. 
 
 TUl!i:KCfl.()SlS Ol-' THE i;soriiAGus. 
 
 Tnlierculosis ol tile esophai^us while relati\el\- mueli more rare than 
 the same process in other viscera, ne\ertheless is ])rohalily not so rare 
 as the literature on the suhject would seem to indicate, hecause in all 
 proljaliilit\ it usually occurs in ]'atients with advanced |iulinonary lesions 
 in which the dithculty in swallowing is Init a minor addition to the 
 rapidly fatal stage of the disease. The ditiicultv in swallowing is often 
 considered to he a part of the laryngeal trouhle. in some instances the 
 larynx is not even examined hy the internist, and in other instances it is 
 probable that laryngeal tuberculosis coexists with the esophageal, and is 
 considered to account fully for all dysi)hagic symptoms. Furthermore, 
 the disease has received such scant consideration in medical literature 
 that it is not likely to Ijc thought of, even in a manifestly tuberculous 
 patient. The disease may occur as a primary infection, or, more fre- 
 (juently, as an extension from a tuberculous jjrocess in the larynx, medias- 
 tinal lymphatics, pleura, the larger bronchi, or e\eii the lung itself. When 
 seen as an extension frcjiii the larynx, especialh- as "party-wall"' lesions, 
 the eso])hageal lesions i)resem nnicli the same picture as the lar\ngeal 
 disease. A\'hen, however, they are primary in the eso])hagus, the endos- 
 copic ajjpearances are rather those of superlicial ulceration or a simple 
 erosion and there mav be \ell(i\\isli or whitish granules in the neighbor- 
 hood of the erosions or ulceration, or the granules may exist alone. 
 Open ulceration means, necessarily, secondary mixed infections, which 
 modily the picture. Cicatrices have been observed onlv twice li\- the 
 author, once in cunnection with ulceration, and once in connection with 
 an invasion of the esophagus by iieri-bronchial tuberculous glandular 
 processes. \\ lieu the disease in\;ides the esophagus from the surround- 
 ing tissues in the mediastinum, there is more or less ct)mpression of the 
 esophagus, and rigidity and fixation with very much impairment of the 
 normal esophageal movements and the transmitteil respiratory and pul- 
 satory movements. The tuberculous |)rocess ma\- h,i\e been found to 
 be completely healed ;ind the result of the cicatricial contraction ma\ be 
 in rare cases, a traction dix erticuhun. The author has seen one such 
 case esophagoscopically. The mncosa did not differ much from the nor- 
 mal, except that it was whiter in color with \essels visible, and did not 
 have the velvet)' appearance of i.onnal mucosa. The fixation was very 
 marked and could easily be demonstraled li\' ir.iclion upon the opposite
 
 564 DISEASES OF THE ESOPHAGUS. 
 
 wall with the distal end of the esophagoscope. demonstrating clearly that 
 the involved wall was partly adherent to the peri-esophageal structures. 
 In one of the author's cases a fistula existed from the esophagus through 
 into the left bronchus. The esophageal end of the fistula was covered 
 with reddish granulations, wliich bled freely when touched, while the 
 bronchial end of the fistula, on bronchoscopy, was seen to be surrounded 
 with a pale mucosa, with small whitish granular elevations in groups at 
 various points. The granulations were pale and did not bleed. They 
 were limited to the margin of the fistula, and did not seem so exuberant 
 as in the esophagus. The ulcerations of esophageal tuberculosis usually 
 are more superficial and less inflammatory in appearance than either can- 
 cer or lues. Some points of difference from these and simple ulcer are 
 given under the head of inflammation and ulceration, Imt the diagnosis 
 of tuberculous lesions here, as elsewhere, will rest largely on the labora- 
 tory findings. Esophagoscopy renders its greatest service in being able 
 to obtain with precision, ample specimens from the lesions. Actinomy- 
 cosis has occurred in the esophagus, though the author has never seen a 
 case. The possibility should be borne in mind in the examination of speci- 
 mens of supposed tubercidosis. In considering the esophagoscopic ap- 
 pearances of tuberculosis, it is necessary to remember that after ulcera- 
 tion has set in that the mixed infections are apt to run riot and that the 
 appearance may be largely due to the secondary processes resulting from 
 this inflammation. One characteristic of the few tuberculous lesions that 
 the auti'.or has seen in the esophagus, is the marked absence of vas- 
 cularity. The mucosa seems pale and the patches whitish, with minute 
 dots of raised whitish color. In one of the author's cases there was so 
 much stenosis of the esophagus that the entire mucosa for some distance 
 above the tuberculous lesions was so pasty from maceration that it was 
 difiicult to outline the lesion, and it was not until after three or four 
 weeks of absolute rest of the esophagus, following a gastrostomy, that 
 the esophagoscopic appearances of the tuberculous lesion itself could 
 be determined. This patient, a man of .'U years, referred by the Pres- 
 byterian Hospital Dispensary, imjjroved very much after gastrostomy 
 and a feeding of large quantities of milk and eggs through the gastros- 
 tomy tube, together with absolute rest in bed. There was a fibroid 
 phthisis in the lung, but no involvement of the larynx. The view, Fig. 
 15, Plate III, is made from a drawing by the author and represents con- 
 ditions after the swallowing had very much improved and there was 
 practical freedom from dysphagia. The mucosa surrounding the tuber- 
 culous lesions is seen to be normal, while the lesion itself is of a dull 
 grayish color and there is a total absence of visible vessels. A specimen 
 of tissue examined bv Dr. W'illetts showed the lesion to be tuberculous.
 
 13ISEASKS OF THE IvSOPII AOUS. .5G5 
 
 Treatment. Local treatment is useless. A general anti-tulierculoiis 
 regime is needed, and al>ove all, if there is any serious difficulty in swal- 
 lowing, gastrostomy should be done at once for feeding in order not to 
 let the [)atient's nutrition suffer, for above all things, nutrition must be 
 kept at the highest possible point of efticiency. Feeding with a stomach 
 tube can be done, but it is exceedingly dangerous in the presence of ul- 
 ceration, and is in some cases painful to the patient. Above all, a gas- 
 trostomy puts the esophagus at rest, which is beneficial to any form of 
 esophageal disease. Orthoform in doses of half a gramme swallowed 
 drj- on the tongue may be used if there is pain, though none of the au- 
 thor's cases of tuberculosis of the esophagus, where the larynx and epi- 
 glottis were uninvohed, have had pain. 
 
 V.'VKIX .■\\D .\NGIOMA oF THE ESOPHAGUS. 
 
 J'ari.v and angioma of the esophagus rarely produce symptoms, and 
 are not ordinarily of very much importance unless they are wounded or 
 they spontaneously bleed. Occasionally a case is encountered where there 
 is considerable bleeding, the patient complaining of regurgitating blood, 
 which is bright red and not of the dark or "coffee ground' character of 
 blood that has been in the stomach. V'aricositles in the esophagus may 
 coexist with "cardiospasm." W hich was the primary lesion has not yet 
 been determined. In one of the author's cases hemorrhoids and varicosi- 
 ties on both legs were enormous. \'aricosities are usually in the lower 
 third (if the esophagus, jiroliably because the veinous system is more de- 
 veloped there than higher up. These veins empty chiefly into the portal 
 vein and a number of cases have been rei)orted where the condition 
 seemed to depend upon obstruction of the portal circulation, as in hepatic 
 cancer or cirrhosis. Careless esoi)hagoscopy producing undue pressure 
 against one lateral w-all will cause an exudation of blood into the sub- 
 mucosal tissue forming a hematoma (Fig. l."):i) which has been mis- 
 taken by a number of esophagoscopists for a varicosity or an angioma. 
 The author has had no experience in treating varix or angioma because the 
 few cases seen by him did not require treatment. Guisez reports the 
 cure of a case of angioma at the cardia by means of r.ulium, and this 
 method seems to he particularly appropriate. 
 
 ANCIONEfKOTlC EDEMA. 
 
 The author has not been so fortunate as to see a case of angioneurot- 
 ic edema, but a very interesting observation of this disease is reported 
 by Arrowsmith (Bib. S), who is an expert endoscopist of large experi- 
 ence. A woman, aged 50 years, complained of difficult and painful 
 swallowing of a few weeks' duration, with history of previous similar
 
 .'iliG DISEASES OV THIC ESOPHAGUS. 
 
 trouble of indefinite duration. Esophagoscopy by Dr. Arrowsmith showed 
 "a mass just below the cricoid cartilage, filling two-thirds of the lumen 
 of the esophagus, with its attachment centered on the left side, .\llo\v- 
 ing for the distension of the esophagus by the tube, this mass undoubt- 
 edly almost occluded it, when mechanical stretching was absent." The 
 mass was also seen by Drs. F. C. Pafifard and I,. Grant llaldwin. Lues 
 being excluded the logical diagnosis of neoplasm, probably malignant 
 was made tentatively, and the case referred to the author who found the 
 esophagus normal and hence concluded the stenosis must have been 
 spasmodic. On further investigation of the case, including the testimony 
 of the patient's previous medical attendants clear history of angioneurot- 
 ic manifestations were discovered by Dr. Arrowsmith to have preceded 
 the esophageal symptoms and later to have accompanied the attacks of 
 tlysphagia and odynphagia. These manifestations were as follows: 
 
 "Commencing with fre(|uent and painful urination and vesical tenes- 
 mus, there would be an extreme irritation of the urethra and meatus, 
 with external appearances suggesting urethral caruncle; alicays followed 
 by symptoms of marked gastrointestinal disturbance and of pronounced 
 pylorospasm. Edema of the larynx placed her in a very critical condi- 
 tion for forty-eight hours. Two months later she had a similar, though 
 milder, attack." 
 
 Subsequent attacks of angioneurotic manifestations were character- 
 ized by pruritic cutaneous wheals, urethral, vesical and gastric symptoms 
 accompanying the attacks of dysphagia and odynphagia. No esophagos- 
 copies were obtainable after the two mentioned, one showing the angio- 
 neurotic eruption in the esophagus and the subsetiuent one showing the 
 esophagus to be normal. 
 
 Treatment, if any, for the condition wnuld be general not esophagos- 
 copic. Passing of a feeding tube with esophagoscopic aid might be needed 
 if the attack were very prolonged. 
 
 .VCTINOMYCOSIS OF THE ESOPHAGUS. 
 
 .-Ictinoinycosis the author has never seen. Its possibility slmuld be 
 borne in mind. Ijut the diagnosis doubtless will rest ui)On the histologic 
 examination of a specimen removed esophagoscopically. Reports of 
 cases so far have been autoptical. 
 
 DEVIATION OE THE ICSOPHAGUS. 
 
 Deviation nf the esophagus is seen not infre(|uentl_\ in cases of 
 mediastinal tumors. The author has encountered one very interesting 
 case of esophageal deviation associated with a spine deformed by a 
 I)reviously healed \ertebral tuberculosis (Eig. 4:i<;a). The patient, a 
 woman aged 41; years, was referred to the author by Dr. ]. W . Fairing
 
 DISEASES Ol" TJIK KSOPUAGUS. 
 
 .-)(i7 
 
 fiir the removal of a cliickun Ijonc from the esophagus. 'I'lie author readily 
 found and esophajjoseopicallv removed the chicken bone withoiU anv prob- 
 lem of interest : but the marked deviation was so rare that the i)atient was 
 sent for a radioo;ra[)h from which to make an illustration ( I'ig. -i:)"-ia). 
 Fluoroscopy with bismuth, by Dr. Iloyce. showed the deviation; but the 
 bismuth bolus went down so rapidly that a stomach tube was used by 
 
 Fi(.. 4.i-'a. — K:nliiij;r''pli nl ;' wuniiiii, ;i>;cc.l 4(1 Mar--, sliuwiiig a deviation of tlit 
 esophagus, that produced 110 symptoms. A stomach lulu- was inserted for demon- 
 stration. (Radiograph made liy Dr. Rnsscll li. liog^s. .\uthor's case. ) 
 
 Dr. lioggs for ra(liogra])hy. I)ou1)tless the esophagus bad been dragged 
 aside by the deviating spine; the dragging being facilitated by the longi- 
 tudinal esojjhageal redimdancy caused by the shortening of the straight 
 distance from llu- Inpopbaryux to the hiatus. The patient had nexcr had 
 anv esophageal svmi)toms and the deviation would not have been discov- 
 ered had it not tieen for the foreign body accident. It is interesting to 
 note that bevond ihe following of the de\iated hnuen there \\a> no dilti- 
 cult\ in esophago>copv notwithstanding a uiarked anterior, as well as 
 lateral, spinal deviation.
 
 CHAPTER XXXV. 
 
 Gastroscopy.* 
 
 The interest awakened by the author's work (Bib. 369, 237, 239) 
 has borne good fruit. In different parts of the world, earnest workers 
 have been perfecting technic and instruments. The author's early con- 
 tention that safety demands that introducing shall be with a tube devoid 
 of a lens system, in order that lesions may be detected and avoided, and 
 that the axis of the instrument may be readily kept in line with the eso- 
 phageal axis, has now been universally accepted. After the distal end of 
 the tube has reached the stomach, a plug with a window has been used 
 in the proximal end of the tube so that positive pressure from an oxygen 
 tank (Janeway) or a hand bulb (Mosher) may be used to push away 
 mucosal folds, and when a lens system is inserted in the tube in the form 
 of a long tube with a window in the side of the distal end, an excellent view 
 of the distended stomach is obtained. The author personally can testify 
 to the beautiful view of the gastric mucosa obtained in the Janeway gas- 
 troscope, and while the use of inflation and of a lens system for gastros- 
 copy is at least thirty years old, yet the optical formula and the par- 
 ticular combination of illumination, lenses, inflation apparatus and tubes 
 in the Janeway gastroscope make it a highly efficient instrument. Excel- 
 lent results have also been obtained by Moure (Bib. 392), Hill (Bib. 200), 
 Eisner (Bib. 128) and others, and all of these instruments are now 
 doubtless developed to a point where the personal skill of the operator 
 counts for more than the particular instrument. The usefulness, 
 safety and practicability of the gastroscope is an accomplished fact. 
 The need now is for careful, skillful men interested in the stomach 
 who will use it. The laryngologist's field is already too large without 
 adding the stomach. The value of gastroscopy in establishing a diagnosis 
 
 •In this chapter liberal quotations are made from the author's Rapport at 
 the International Medical Congress, London. 1913. and from his paper read by 
 invitation before the New York Academy of Medicine, Jan. 23, 1907.
 
 GASTROKCOPy. 5GSJ 
 
 in severe and oljscure stomach disease has hccn ahundaiUly pnived. The 
 tendency, however, to resort to it only in very serious conditions often 
 prevents one of its greatest achievements, which would be in the early 
 diagnosis of cancer and of pre-cancerous conditions. When endosco- 
 pists who have developed the gastroscopic technic, arc sufficiently numer- 
 ous and sufficiently skilful so that the physician or the surgeon may feel 
 justified in sending them cases before the patient's condition becomes 
 desperate, gastroscopy will be of great use to the physician and surgeon, 
 but gastroscopy probably will never be done by the physician or the 
 surgeon himself. He will take the endoscopist's report along with that 
 of the radiographer and analyst and decide as to the best handling of 
 the case, just as the otologist in a brain case takes the report from the 
 internist, the laboratory, and the ophthalmologist. Unlike tracheo- 
 bronchoscopy and esophagoscopy, it may be said of gastroscopy that 
 while its positive reports are extremely \aluable, its negative reports are 
 less so, just as with ophthalmoscopy in brain disease, the Wassermann 
 reaction, and many other of our most valuable aids in medicine and 
 surgery. A very important point in increasing the range of mobility of 
 the distal end of the gastroscope in the stomach has been demonstrated 
 by Henry Janeway. It consists in an elevation of the knees of the re- 
 cumbent patient to the vertical or flexed position, as this relaxes the 
 abdominal wall. 
 
 Seven years' addiliunal experience have shown the correctness of 
 the statement (liib. 'ii)\) ) that there is no huiiian being with a normal 
 spine and a normal eso])liagus into whose stomacii a straight and rigid 
 gastroscope cannot be readily and safely introduced, provided: (1) 
 The i)atient is fully anesthetized. (2) An ojien tube of light construc- 
 tion is gently passed by sight. (;!) The patient's head is held in 
 the Boyce position. (4) The operator is a skilful esophagoscopisl. 
 
 Statements to the contrary are the result either of inexperience or 
 of experience with gastroscopes that cannot be passed by sight. Flexible 
 guides are unnecessary, rarely of aid, and are dangerous. The inexperi- 
 enced will have trouble at the cricopharyngeus, but surely no esophagos- 
 copisl will. It required only thirty-eight seconds, in the author's clinic, 
 for Professor Killian, in his careful, skillful w-ay to pass the author's 
 gastroscope from the mouth to the greater curvature of the stomach. 
 The writer cannot understand why so many authors have stated that they 
 had difficulty in passing a rigid instrument through the cardia. All diffi- 
 culties are o\ercome by carefully following the directions given under 
 "Introduction of the Esophagoscope." 
 
 It is true that we do not always get a complete view of the gastric 
 mucosa, but as Ilalstead has pointed out the same may be said of the
 
 ."i^ll C.ASTKOSCOPV. 
 
 nasopharynx. Indeed the author knows of no case of gastroscopy where 
 he has failed to get a view of the stomach, which is more than can be 
 said of the nasopharynx by ordinary methods of examination. 
 
 Some recent experiments by Rosenow in the production of gastric 
 ulcer by the injection of streptococci opens up a wide field for gastro- 
 scopic study on the dog. 
 
 Mortality of gastroscopy. That there is practically no mortality from 
 gastrosco]iv in \ery careful hands has been shown by the replies to the 
 author's circular letter of iiK|uiry. Out of 110 cases done by eight dif- 
 ferent endoscopists there was no mortality from any cause within two 
 weeks after gastroscopy. The author has now examined the interior of 
 2;5S living stomachs with the peroral gastroscope, and so far onlv one 
 patient has died from any cause whatever within one month after the 
 gastroscopy. . As previously reported, this patient was moribund from 
 a bleeding ulcer of the stomach when admitted to the hospital. I'.ut. 
 taking the figures just as they stand, the mortality is onl\- a fraction of 
 one per cent. 
 
 'rcclinic of (/nstroscopy. In the main the description of the technic 
 in the earlier publication ( liib. Sii!)) is correct and has stood the test 
 of further experience. Introduction with mandrin and finger, however, 
 was abandoned by the author before the book was off the press and the 
 gastroscope was passed by sight as described in Chapter X. The author 
 still uses the open tube gastroscope. but believes that, after all the data 
 thus obtainable have been noted, the use of a lens system in the open 
 tube will in a proportion of cases yield additional information, and is a 
 \-aluable acquisition. The advantages of the open tube are the undis- 
 torted image, the facility of probing, removal of a specimen of tissue or 
 fluid, siionging awav a coating of secretions, etc. When one dilates the 
 stomacli lie pushes its walls far away from the reach of the tube : walls 
 which otherwise would collapse over the tube mouth, to be examined 
 and palpated by the probe and tube. The portion of the stomach near- 
 est the centre line of the body is the most easilv examined. The col- 
 lapsed stomach is relatively small, and much of it is near the middle 
 line (Fig. -l.'S:)). ^^'hen one distends the stomach he pushes most of 
 the otherwise ex])lorable area away from the central line and thus later- 
 ally out of range. The diaphragm is rendered much less movable when 
 the stomach is distended, and. furthermore, thus is rendered impossible 
 the practice of a most \akiable part of the technic. iiamel}'. the luanipu- 
 lation of the abdomen externally by an assistant, which brings into view 
 the fundal and pyloric ends. A lens system and an inflated stomach 
 prevent .sponging away of secretions with which manv lesions are 
 covered. The position ;uid shape of the stomach in the living subject
 
 GAS'KROSCOPY. iVl 
 
 has hecn iimst citrimisly misunderslood. Fig. IHJ is traced I'nmi (nu- of tlic 
 classical tcxl-houks on anatomy. Whatever may be the position and 
 shape of the stomach in the ca<huer or in the Hving subject after the 
 abdomen is opened, it was certain1\- not in an\- such |iosition in any of 
 the ".^.'iS cases examined gastroscopically by the author and it may be 
 said that the stomach is of such shape as to fit whatever space is avail- 
 able at the particidar moment. Tlie author's method of oiitHnini; the 
 st(.>macli is to find a gi\en boundary with the extreniit\- of the tube. The 
 
 fi^ 
 
 Fif'. 4.3.?. — Positicin of tlie stomach in the case of Isabel A. Crosses show 
 where the wall of the stomach was iptentinnally pusht'd by the gastroscopc. The 
 schema in the upper right hand corner shows the other planr of the stomach. 
 
 rlistal end of the tube is felt by the abdominal |)alpalor, who makes a 
 mark on the patient's skin with a skin ])encil. .\nother ])f)sition on the 
 boundarv is then found and marked, and thus a series of marks dot the 
 skin of the abdomen correspondin<,f to the stomach outlines. .\n obvious 
 source of error is the drajj of the tube, which may displace the stomach. 
 This can be .'uoided by a careful watch lln-ou^b the lulu- ,ind care to 
 make a \ertical insertion for each mark. This gi\es the jiosition of the 
 stomach when empty. The radios,n-;iph, which is more tjenerally usefid. 
 gives the jiosition when conlainiiig fluid or food. The stomach wall 
 can be pushed into .-dmost any position, as shown in l'"it;. \'.V-\, which illus-
 
 572 
 
 GASTROSCOPY. 
 
 trates the position of the stomach in the case of Isabel A. (Bib. 239). 
 The stomach gave the impression of a loose bag dangling on the end of 
 the gastroscope, freely movable in all directions, by either the movement 
 of the gastroscope or the manipulations of Dr. Harold A. Miller, who 
 was palpating the abdomen externally. The diagram at the upper right 
 hand corner of the illustration shows schematically the other plane as it 
 appeared to be when gastroscopically examined. Passing down the esoph- 
 agus, as soon as one passes the cardia, folds and wrinkles are en- 
 countered, a slight deflection bringing either the anterior or the posterior 
 wall into view. The degree of motion shown in Fig. 43;5 is obtainable 
 
 omy. 
 
 Fig. 434. — Position ot the stomach as shown in a classical text-book on anat- 
 
 only imdcr the relaxation of deep anesthesia. When gastroscopy is at- 
 tempted, under morphine narcosis, as Mikulicz attempted it, the muscula- 
 ture of the diaphragm pulls upon the central tendon, so that the gastro- 
 scope is guyed rigidly like a tent pole, and if the stomach can be entered 
 at all, only such portion can be inspected as lies in a line with the axis 
 of the entry of the tube. When relaxed under deep anesthesia the hiatus 
 esopliageus does not relax or enlarge so as to permit of motion ; but the 
 entire dome of the diaphragm can be moved sidewise because it is of 
 dome-like form. If it were a tightly stretched membrane, as shown by 
 the dotted line in Fig. 43.5, there would be no yield in any direction ;
 
 GASTROSCOPY. 
 
 573 
 
 tiut being arched (as shown in Fig. A'A') ) its "slack," as one might say, 
 permits of a range of motion of from JO to 15 cm., provided the central 
 tendon is so relaxed by deep anesthesia as not to be pulled upon from all 
 sides by the diaphragmatic musculature. A range of lateral motion of 
 seventeen centimeters was observed by Dr. J. Hartley Anderson in the 
 opened abdomen of a living patient. This movement was imparted 
 solelv bv the gastroscopist manipulating the gastroscope by its proximal 
 end. Dr. Anderson with gloved hands grasping the gastroscope could 
 I)lace it anywhere in the unopened stomach, and any part of the wall 
 could be moved to the tube mouth. One of the most promising fields for 
 
 Pic. 435. — Illustrating tlic anatomical reasons tor the wiile range of molality 
 of the gastroscope in the stomach. If the diaphragm were a plane or tightly 
 stretched membrane as represented l>y the dotted line a gastroscope in the hiatus 
 could not be moved laterally. The dome shape permits of a wide lateral range 
 of movement because of redundancy, provided the diapliraymatic muscidatnre is 
 rela.\ed by deep anesthesia. 
 
 open tube gastroscopy is the aid rendered by the endoscopist as an as- 
 sistant of the abdominal surgeon, who will assist the surgeon not only 
 in diagnosis, but in the operating room during the operation, by working 
 ibrougli llic niiiulh in (.-oniinu'tidn with the siu'geon whose hand is in the 
 opened abdomen. The endoscopist, of course, has his own instrument 
 nurse and sterile organization at the head of the ]>atient, entirely sejiarate 
 and apart from that of the abdominal surgeon, to whom the endoscopist
 
 o7i C.ASTROSCOI'V. 
 
 can give a prompt report on the interior appearance of any suspicious 
 portion of the stomach wall palpated and presented at the tube mouth 
 by the surgeon. The suspected tissue is placed in front of the tube 
 mouth ]iv the surgeon whose hands are in the opened abdomen palpating 
 the, as vet. imopened stomach. Extensive citation of cases would unduly 
 expand this book. A few will serve for illustration. 
 
 Case I, XIX. Daniel B., aged sixty-two years, was admitted to the 
 Western Pennsylvania Hospital to the service of Dr. John W . ISoyce. 
 complaining of feeling weak, and of loss of appetite, emaciation, and 
 headache, all these symptoms appearing gradually about one year pre- 
 viously. There was no nausea or vomiting. The temperature was 
 normal, the pulse 00, and the respirations v!4. After the mouth of the 
 gastroscope passed the cardia. in the first -l cm. of the passage, the an- 
 terior and posterior walls of the stomach opened up in normal folds 
 ahead of the tube mouth. Below this, however, the tube mouth entered 
 a cavity with smooth unwrinkled walls. At the bottom of this cavity 
 was a crescentic slit-like depression looking somewhat like the primipar- 
 ous OS uteri (C, Plate \'). When the mucosa was sponged clean of 
 bubbly secretion, the slit-like depression was found to have a considerable 
 depth, which, however, was not probed, although to have done so would 
 have been technically easy and probaiilv harmless. The surrounding 
 mucosa was of pale pink color, without rugae, and when the tube mouth 
 was withdrawn the depression was still visible in the same position in a 
 cavity, the wall of the stomach at this point being evidently held open 
 by adhesions to the abdominal parietes or viscera. Fully to appreciate 
 the picture, it is necessary to realize that the empty stomach is collapsed. 
 When examined gastroscopically, it opens up ahead of the tube and col- 
 lapses after its w ithdrawal, in a manner similar to that of the vagina upon 
 the introductiiin and withdrawal of the \aginal speculum when used upon 
 a patient in the dorsal position. But here was a case in which the an- 
 terior wall of the stomach was adherent, so that it was held up ( dorsal 
 decubitus ) ; thus the posterior wall dropped away by gravity and left a 
 cavitN'. The cicatrices and adhesions were such that no mucosal folds 
 could be ])roduced in the neighborhood of the slit. When Dr. (Jgilvie 
 tapped upon the abtlomcn the vibrations were seen to be beautifully trans- 
 mitted in waves over the upper ( anterior ) wall of the stomach. The 
 picture was beautifully clear, and the author and his colleagues, who saw 
 for themselves, felt justified in pronouncing the lesion the cicatrix 
 of a healed i>erforating gastric ulcer. Mad it been an operable lesion, 
 it coulil have been precisely located by holding the tube mouth against it 
 while the abdominal surgeon cut through the stomach wall from the 
 celiotomic wound.
 
 GASTKOSCOl'V. o75 
 
 Case XX. Margjarct 7... a st-rsam at tlic \\'estcrn rennsylvania 
 Hospital. Six months hcforc, gastrojejunostomv had been performed 
 by Dr. Cieorgc L. Hays. Complete symptomatic cure had followed. 
 Under general anesthesia, the author passed the gastroscope, and readily 
 found the anastamutic opening; in the form of a slit, which, when pulled 
 open b)- the instrument, showed a slightly puckered border, below which 
 could be seen the mucosa of the jejunum (.A., f'late \ ). 
 
 Dr. W". 1. Rodman, with my assistance, examined gastroscopically 
 a gastrojejunostomy wound two weeks after the operation, and saw the 
 opening and the non-absorbable sutures in situ. His report on the 
 examination is as follows : 
 
 ■"The patient was etherized, brought Ijefore the class, and the gas- 
 trosco]je introduced. Tt was surprising to me how well the interior of 
 the stomach could lie inspected. The gastroenterostomv opening was 
 plainly visible, was found to be patent and working perfectly, and the 
 Pagenstecher or linen thread used as a suture material was ])lainly seen. 
 I see in gastroscojiy a valuable addition to our diagnostic resources in 
 gastric diseases, provided the instrument can be employed by one skilled 
 and deft in its use. Particularly will it be valuable at the time of an 
 exploratory laparotomy, inasmuch as the gastroscope can be so guided 
 that even the j)ylr)ric end of the stomach can be brought clearly in view. 
 The case above referred to was discharged from the hos])ital as cured 
 a few days later, lie was a very intelligent F.nglisbman and was com- 
 forted by the assurances gi\en him li\ Dr. Jackson after an inspection 
 of the gastric mucosa. 'i"he patient had suffered long, had become ad- 
 dicted to morphia, and feared that he had carcinoma. This was the 
 first time that gastroscopy was j)racticed in riiiladeli)hia. 1 ma\ add 
 that a letter received months after his return to I'jigland stated that he 
 was enjoying perfect health.' 
 
 'l"he author has disco\ered great adxantagcs in jilacing tlie patient 
 face downward with a pillow under the chest, and in some instances 
 under the peKis also, in order to get the assistance of gravity in dro])- 
 ping forward the abdominal wall. It is not generally realized the extent 
 to which the sjjine curves forward .-md projects into the alidomen as 
 well as MUo the tlioracic cavities. This anterior projection into the ab- 
 dominal cavity interferes seriously with gastroscopic examination oi the 
 pylorus, because in the dors.il position there is a tendency for the py- 
 lorus to drop backward and reach a plane ])oslerior to that of the mid- 
 dle portion of the stomach that is prevented from dropping backward 
 by the anteriorally projecting spine. In the use of lens systems, the 
 gastroscojiists ha\e been misled into thinking the\ were looking at the 
 pylorus, when really they were looking at onl_\ a more or less fuiuiel-
 
 576 GASTROSCOPY 
 
 shaped cavity formed by the limited area of the stomach wall that was 
 inflated. This gives in miniature, the same general shape as the pyloric 
 antrum, and it is the tendency of all lens systems to deceive one as to 
 the actual size of the visual field. 
 
 Presbyopic gastroscopists should have a special pair of glasses 
 with a 60 cm. focus, as the glasses for ordinary reading distance will blur 
 the more distant gastroscopic image. 
 
 Gastroscopy for foreign bodies. The esophagoscopist is often con- 
 sulted in regard to foreign bodies that have reached the stomach. The 
 author's opinion is that the great danger in the swallowing of foreign 
 bodies is that they will lodge in the esophagus, where serious, even fatal, 
 ulceration may occur. Once they have reached the stomach they are 
 relatively safe. This does not mean, however, that it is ever justifiable 
 to attempt to push a foreign body down by the blind methods, or by 
 esophagoscopic methods, because it is his belief that any foreign body 
 that has gone down through the mouth can be brought back the same 
 way. Xor is it to be taken that once a foreign body has reached the 
 stomach that the patient can be told to pay no more attention to the 
 matter. On the contrary, every foreign body that is known by the ray 
 to have reached the stomach, should be watched. So long as it remains 
 in the stomach, it is relatively safe. When it reaches the intestines, as it 
 usually does within from one to three days, it should be watched every 
 alternate day radiographically, in order to make sure that it is moving. 
 Should it lodge in one position for five days, a laparotomy should be 
 done at once for its removal, as it will certainlv perforate. Quite a num- 
 ber of perforations of the ileum have been reported, some recent cases 
 by SteifF, Ross and Hodge. The author had one case in which consent 
 to esophagoscopy was refused when the needle was in the esophagus. 
 Later when lodged for five days in the intestines, the family was urged 
 to allow a general surgeon to do a laparotomy. Consent to this was 
 also refused and the child died of a septic peritonitis following perfora- 
 tion. 
 
 Tn all cases, great care should lie taken to avoid cathartics. 
 \'ery bulky foods, such as potatoes, bread, oatmeal and the like, should 
 be given freely in order to distend the bowel and embed the foreign 
 body. The insane and the intoxicated, and also some performers, swal- 
 low very large and sharp objects, such as open pocketknives, glass, etc. 
 A large number of such objects have been removed from a single stom- 
 ach. All such cases deman<l immediate external operation by a general 
 surgeon. In case of such a body as an open safety pin, the author would 
 advise laparotomy by the general surgeon rather than take a chance of 
 its not perforating in passing through the intestines, because of the com-
 
 GASTROSCOPV. 0(7 
 
 hiiialion (_)f tliu point and llie sprin^i;'. ll is ((uite iiossihlc that it mii;ht 
 pass harmlessly, hut on the other hand the risk of perforation is great. 
 Assisted by a fluoroscopist using the Grier double-plane fluoroscope, the 
 gastroscopic removal of foreign bodies is easy, with the author's gastro- 
 sco])e. 
 
 ( )pen-tuhe gastroscopes (such as the author's esophagoscope Fig. 19) 
 are the only forms available for the removal of foreign bodies. Forceps 
 cannot be used through lens-system gastroscopes. 
 
 Castroscopv tlvonoli the celiotoniic wound. For this purpose a 
 thick short tube should be used. .\ very ingenious speculum for the 
 
 Fig. 43O. — A, open tube. B, light carrier to be used during introduction. C, 
 large lamp needed uitli lens system. 11, lens system. K, open tube lor use witli 
 large lamp. 
 
 purpose has been devised by Robert Rendu. It is expansile at its distal 
 end and gives a large visual iield. 
 
 I.ciis-svstciii t/astroscopy. .Alter having obtained all possible data 
 from open-tube gastroscoi)y, a lens system may be introduced. The 
 Tanewa)' gaslroscf)i)e is shown in Fig. bU!. The introduction of the 
 open tiilie is bv the author's nicthnd as described in Chapter X. Th^-ii 
 the small lamj) carrier, 11. is withdrawn and the large lamj) carrier, C, 
 is introduced. Next the lens carrier, I), is pushed inside of the hollow 
 large lamp carrier. The lens carrier displaces the large lamp sidewise, 
 permitting l\\v window of the lens system to jiroject beyond the distal 
 end of ihc dpen tube. I )xygen from a tank, or air fr(un .a cmiipression 
 tank (ir liand b.all. is then used to distend the stomach while llie degree 
 of distension is watched through the tube. It seems prnbable that, as
 
 378 GASTRoscopy. 
 
 suggested bv Janeway, the air or oxygen that escapes around the tube 
 in the esophagus would prevent an injurious degree of pressure. This 
 must not be relied upon, however, and caution against over-distension 
 is advisable. The distended area in the stomach assumes a funnel-like 
 form ending at the apex in a depression with radiating folds that leads 
 the oliserver to think he is looking at the pylorus. This illusion is con- 
 tributed to by the foreshortenings of the image of the lens system. Prop- 
 er comprehension of the image necessitates familiarity with the par- 
 ticular instrument used. This must be ac(|uired by practice on a mani- 
 kin which can be readily devised from an open box. which permits com- 
 parison of the image with the corresponding naked eye view. 
 
 A good illustration of endoscopic views of the stomach through the 
 Janeway lens system is shown in Plate \'l.
 
 Part II. 
 
 Laryngeal Surgery. 
 
 I.\'I'R()DL:CTI()N. 
 
 It is not intended here to teach the fundamentals of modern aseptic 
 surgery. 'I'lie reader is supposed to have had a number of years of 
 practical training in a good clinic under a master of surgery. 
 
 Operatmy room organization. Modern surgery is not the work 
 of one man but of an organization. It is impossible for one man to at- 
 tend tf) all the details of the modern operating room, and he is dependent 
 upiiii tlie conscience, skill and ahilily of his assistants, nurses, radio- 
 graphers and otliers. The organization does not need to be large, but it 
 must be harmonious and each must work for the common good rather 
 than to satisfy personal ambitions. Tlurc must be no failure upon the 
 part of any nurse, instrument or apparatus at a critical moment, in short 
 it is in every sense of the word, "team work,'' and ])ractice together is 
 essential for the best results, as in a football leani.
 
 CHAPTER XXXVI. 
 
 Acute Stenosis of the Larynx. 
 
 For the present purpose any condition that narrows the lumen ot 
 the larynx and immediately subjacent trachea in a relatively short time 
 may be considered an acute stenosis. Such narrowing may be due to 
 a foreign body ; to accumulation of secretions or exudates ; to distention 
 of the tissues by air, inflammatory products, serum, pus, etc. ; to dis- 
 placement of relatively normal tissues as in abductor paralysis, con- 
 genital laryngeal stridor ; to neoplasms ; to granulomata. Two or more 
 of the foregoing may be combined. In fact, the stenosis in almost all 
 cases, whatever the cause, is mechanically increased by the presence of 
 secretions, temporarv inflammatory conditions, etc., in the already nar- 
 rowed lumen. 
 
 Edema of tlir lary)ix is the most freciuenily heard of acute stenotic 
 condition. The name, however, has been used too generally in the ab- 
 sence of means of accurate diagnosis especially in children, ]irior to the 
 advent of direct methods of examination which have recently rendered 
 accurate diagnosis possible. Edema may be glottic, supraglottic or suli- 
 glottic. Strictly speaking, the name glottis refers to the chink or lumen, 
 and cannot be affected with edema, Xevertheless the bordering tissues 
 can be edematous, and "glottic" in this case is used to mean a region. 
 As a pathologic fact, however, the vocal bands are rarely, themselves, 
 acutelv edematous, though thev are fretpicntly pushed inward by the 
 edema of the basal tissues, and thus the cortlal edges encroach on the 
 glottic lumen, though not themselves edematous. .As shown by Logan 
 Turner ( llib ~ii2 1 the loose cellular tissue is most fre(|uentlv concerned 
 in laryngeal edematous processes, .\cute inflammatory stenosis may be 
 associated with relatively superficial mucosal and submucosal inflamma- 
 tion or with perichondritis. These processes may be primary or may 
 com])licate many general diseases, especially typhoid fever, 
 
 .-Iciite larynqeiil stenosis cnm/'iicating typhoid fever deserves espe- 
 cial consideration, as it is frequently overlooked and the patient is per- 
 mitted to die without a suspicion of the laryngeal stenosis, because these 
 patients, in many instances, make no fight for air anil often are only
 
 ACUTK STENOSIS OF TlIK LARYNX. 
 
 581 
 
 sliglitlv. if at all, affected liy Imarscncss as shown hy the author in an 
 extensive stiuly ni the larynx in typhoid fever (Kih. 2.52). A typical 
 case of acute stenosis complicating typhoid fe\er reported by J. H. Bryan 
 I'Bib. ofi ; is particularly valuable as giving an accurate description of 
 the living laryngnscojiic ])icture by a Ween, experienced observer. A 
 
 Fig. 4.V. — Photograph of spccinitn of larynx acutely stenosed by perichon- 
 dritis complicating typhoid fever in a man aged forty years. A, gap where speci- 
 men was excised post-mortem. B, necrotic left arytenoid cartilage hanging by a 
 shred. C, necrotic area from which right arytenoid cartilage necrosed and dis- 
 appeared before death. I), interior view of trachootomic wmnid. Specimen lent 
 by Maj. Frederick Russell, l'. S. A. I'atimt of Dr. Jn>.cpli H. Bryan. 
 
 photograjili of the aiUoptic s|iecinu'n i> repr(]duced in l'"ig b'i7 by cour- 
 tesy of Maj. Frederick 1\. Russell. Surgeon. U. S. A., who kindly lent 
 the author the specimen from the .Museum of the Siu-geon (leneral's 
 cilice. .Acute laryngeal stenosis in typhoid fever may be due to cordal 
 inmiobiliiy from either paralysis or intlamniatory arytenoid fixation in the 
 absence of edema.
 
 ,583 ACUTK STENOSIS OF TUK LARYNX. 
 
 Laryngeal stenosis in the new-born. Another class of cases is the 
 children born with laryngeal stenosis of anomalous morbid or traumatic 
 laryngotracheal stenosis. Examples of these are not common compared 
 to the number of births, but doubtless are usually overlooked when they 
 do occur because they are simply put down as a "blue baby." The dis- 
 tinguishing feature is that whereas a "blue baby" from failure of the 
 foramen ovale to close is pumping the air in and out regularly, and a 
 "blue baby" from apnea does not make the respiratory movements, the 
 laryngeally stenosed baby is making the respiratory movements but little 
 or no air is passing in or out, and there is indrawing at the suprasternal 
 notch, around the clavicles, and, in some cases, even in the epigastrium. 
 The following case communicated to the author by Dr. Freeland is so 
 complete and accurately observed that it may be taken as typical. 
 
 "Female : full-term : 7 pounds ; lived twenty-four hours. Easy for- 
 ceps delivery. Mother had right-sided pyelitis with temperature 101 to 
 103, pulse no to 100, for three days before delivery. Cords pulsating 
 strongly and regularly and child had a good color on delivery. Made oc- 
 casional voluntary etiforts at inspiration, but gradually passed into con- 
 dition of white asphyxia. Resuscitated by hot bath and mouth to mouth 
 artificial respiration. After ten to fifteen minutes was breathing regular- 
 ly and had a good color. Never cried. Respirations shallow. From this 
 time on there were repeated attacks of secondarv asphyxia from which 
 the child was revived with oxygen and mouth to mouth insufflation. After 
 four to six hours these attacks of asphyxia were accompanied bv the ex- 
 cretion of frothy brownish mucus from the throat and lungs. Respira- 
 tions were always shallow and labored and the accessory muscles con- 
 tracted strongly with each inspiration, even after resuscitation from at- 
 tacks of asphyxia. The lungs were full of moist rales, the respiratory 
 nuirmur was \ery short and much less pronounced than the usual in- 
 fantile type. Except for some retraction of the head there was no evi- 
 dence of cerebral hemorrhage. The child died in twenty-four hours in 
 an attack of asphyxia, having been kept barelv alive for some hours 
 by constant watching, oxygen, removal of mucus from the throat and 
 mouth to mouth artificial respiration. It never cried, a point that did 
 not receive much attention until the autopsy was performed. The clinical 
 diagnosis was atelectasis. Autopsy was performed by Dr. Andrews, who 
 found: Malformation of larynx, sub-dural hemorrhages, bilateral. He- 
 matoma of scalp, right side. Subserous hemorrhages of lungs and heart. 
 Inflammatory foci in right lung. vSubcutaneous hemorrhages. Anemia. 
 Larynx; cricoid and arytenoid cartilages are much thickened and firmer 
 than normal. The glottis is very small, just atlmitting the head of a 
 moderate-sized probe. The vocal cords are shortened, thicker and firm-
 
 ACfTIC STENOSIS OF THK LARYNX. 583 
 
 er than normal. Kcmarks : The patholojjy found wa.s donlitless all sec- 
 ondary to the laryns^cal stenosis. Death was by asi)hyxia. 
 
 The author has seen three cases of acute laryngeal stenosis from 
 perichondriti-; in infants a few weeks old. The thymus gland was large 
 in all three cases, probably due to the vascular engorgement of dysp- 
 nea, and, had the ciiildren died, the death would have been attributed to 
 status lymijhaticus. In each of the cases direct examination revealed 
 laryngeal stenoses and a total absence of thymic or any other tracheal 
 comjiression, and, most important of all, tracheotomy completely relieved 
 all the symptoms, the children recovered and were decannulated after 
 the cure of the laryngeal stenosis. As to the cause of the perichondritis 
 the author is unalile to say positively. The cases were all forceps de- 
 liveries, and traumatism either during accouchement or clearing the 
 mouth and pharynx afterward might have been a factor. The father 
 of one of the patients was luetic, but neither lues nor tuberculosis has 
 appeared in any of the three children though they are now two, three 
 and six years of age respectively. The stenotic symptoms began in all 
 three of the cases between the second and the fourth week. The author 
 at i^resent, has another similar case of stenotic laryngeal ])erichondritis, 
 starting three weeks after delivery and reaching the almost fatal point 
 in the eighth week, 'i'he laryngeal nature of the trouble was recognized 
 by Dr. W illiani Kirk who sent the case to the author. The child was mori- 
 bund from stars atif)n and loss of sleep. It had been so busy fighting for 
 air that it had no time for eating and sleei)ing. The left side of the 
 subglottic region was bulged in until there was only a slight crevice left 
 through which to breathe. The swelling was lirmer than an edema and 
 contained i)us. The author did a tracheotomy with conii)lete relief of the 
 dyspnea after which it nursed and slept normally. A quantity of muco- 
 pus escaped from the trachea as soon as the tracheal incision was made. 
 Like all the other patients, it gave the usual tracheotomic sigh of relief 
 and respiratory pause after the trachea was opened. 
 
 'i'he glottis normally is relatively narrow in the newdiorn, 
 Surcjical treatment of acute laryngeal stenosis. ^Multiple puncture 
 of acute inflammatory edema is readily accomplished with the knife, Fig. 
 85, used through the direct laryngoscope, P"ig. 14. As a rule, however, 
 this is by no means certain to be helpftU for any length of time and 
 recrudescence of the edema may be fatal in the absence of a tracheotom- 
 ist. In view of this, and especially in view of the great therapeutic effect 
 of tracheotomy in all intlannnatory states of the larynx, tracheotonix' 
 should, in most cases, be done in ]ireference. Intubation is treacherous 
 mill unreliable in all excejit diphtheritic cases. In the latter, O'Dwyer's 
 intubation is ideal, if the p.alieiil \k- earefulK watched.
 
 CHAPTER XXXVII. 
 
 Tracheotomy. 
 
 INDICATIONS FOR TRACHEOTOMY.* 
 
 As a therapeutic measure in diseases of the larynx, tracheotomy 
 should occupy a more prominent place than has ever been accorded to it. 
 Whether the therapeutic effect is due to rest of the larynx or not, the 
 author is unable to say, but the effect in many diseases is abundantly 
 proven according to his experience. Inefficacious antiluetic treatment 
 of luetic laryngitis has immediately produced results after tracheotomy. 
 A number of writers have discredited tracheotomy in tuberculosis. The 
 author's experience has been quite the reverse. In a number of cases 
 with advanced laryngeal tuberculosis, but with relatively slight lung 
 lesions, marked improvement and relative cures have followed tracheo- 
 tomy, combined in some instances with the healing of ulcerations and the 
 reduction of infiltrations by the galvano-cautery. These jirocedures en- 
 abled the patient to be nourished systematically in cases in which the pa- 
 tient was rapidly declining because of inanition, owing to the odynphagia. 
 Tracheotomy was done in these cases only partly for the purpose of 
 rest of the larynx, but mainly to permit of perfect ventilation of the 
 lung, which was but inefficiently carried on through the narrowed glottic 
 chink. Perichondritis and other inflammations of any etinlogv are often 
 very promptly benefited by tracheotomy. 
 
 Tracheotomy for foreign bodies is no longer indicated either for the 
 removal of the intruder or for the insertion of the bronchoscope. In the 
 absence of a bronchoscopist the surgeon is perfectly justified in relieving 
 dyspnea in a foreign body case by tracheotomy. Tracheotomy ma\- be 
 urgently indicated for foreign body dyspnea, but not for foreign body 
 removal. 
 
 / ra'-heotomy for respiratory arrest. In the absence of anv stenosis 
 of the larynx, tracheotomy may be urgently indicated in respiratory ar- 
 
 •This chapter is a revision of a lecture delivered by the author, by invitation, 
 before the Philadelphia Laryngological Society, Sept. 23, 1913.
 
 TRAciii:oTOMv. 585 
 
 rest for the iiivitft'lation of oxygen and aniyl nitrite. ( Jrdinary Sylvester 
 artificial resjjiration is much more et'ticient if a tracheotomy has heen 
 done because it eliminates the pharyngo-laryngeal "death zone." The 
 pulmotor and similar apparatus are fairly efficient. Bronchoscopic oxygen 
 insufflation is better than either, if available. Paralysis of respiration 
 in bulbar palsy, cerebellar abscess and the like may produce intense 
 cyanosis, for which tracheotomy may not be indicated. lUit unless the 
 diagnosis is certain from previous study of tlie case, arrest of respiration 
 with cyanosis is always an indication for tracheotomy. The cause can 
 be ascertained later. Many times more i)eoiile have died for want of a 
 tracheotomy than have ever died from the operation. 
 
 'i'here comes a time when a patient luay die because he can no long- 
 er stay awake to breathe. \\ hen he attempts to doze, the loss of the 
 accessory muscular activity de])ri\es him of air and he is wakened by 
 threatened asphyxia. We all preach early tracheotomy, but practically 
 always do it late — dangerously late. Rarely indeed is it justifiable to 
 wait for cyanosis, or still worse, ashy gray '"cyanosis." W hen res|)ira- 
 torj' arrest comes from laryngeal or tracheal obstruction it comes abrupt- 
 ly. Five factors contribute to relatively sudden death in dyspneic cases. 
 
 1. The patient from waiU of sleep reaches the point where he can- 
 not longer stay awake to breathe. 
 
 2. Secretions accumulate rapidly toward the last because the laryn- 
 geal conditii'n interferes with expectoration. 
 
 '■). The patient \\(irn out by his fight for air gives up froiu ex- 
 haustion. 
 
 The foregoing three factors ajiiil) with es|iecial force to dyspnea of 
 gradual onset and especially in children. 
 
 4. X'enous engorgement suildenly increases in increasing progres- 
 sion as dyspnea increases. Thus a vicious circle is established. 
 
 5. \ny excitement or struggle increases dyspnea, hence the first 
 steps of an nperation or of attem])ted aj>j)lication of an anesthetic in- 
 haler, preciiiitatcs respiratory arrest. 
 
 It is particularly dangerous to postpone tracheotomy over night im- 
 less a good experienced tracheal nurse is watching the patient. Too 
 often nurses who are ordinarily good and well-trained, but inexperienced 
 in tracheotrmiy. will tliink the p.atient is "sinking" when reallv be is 
 asphyxiating. Death Inr want of a tracheotomy has resulted from the 
 failure to recognize that a i)atient with a monolateral paralysis is in con- 
 stant danger of asphyxi.i in two ways: ( 1) The iNiralysis mav become 
 bilateral. (2) There m;iy !)e bilateral adductor spasm (or si)asm of the 
 mobile cord I. The first of these is more often recognized than the lat- 
 ter, for it does not seem to be generalU' known that se\ere and dangerous
 
 oSti TRACHEOTtlMV. 
 
 l)ilateral spasm even in a palsied cord, may be caused from a mediastinal 
 pressure effecting both the afferent and efferent vagal fibers. The au- 
 thor has seen such cases. If a patient with monolateral recurrent paraly- 
 sis goes where he cannot be watched, he does so at his peril. Tracheo- 
 tomy may be indicated as a preliminary procedure to laryngectomy and 
 other procedures. It is sometimes needed to relieve bechic air pressure 
 in order to obtain healing of the plastic flap, in the closing of tracheal 
 fistulae. Angioneurotic edema of the larynx is usually an urgent indica- 
 tion for early tracheotomy. 
 
 Siihcutarcoiis rupture of the trachea from external trauma may ne- 
 cessitate tracheotomy as shown in the following case. Tiie author was 
 called to the Presbyterian Hospital to examine a case of extreme dysp- 
 nea and cyanosis. He found a boy of fifteen years admitted with a his- 
 tory of having fallen down a flight of steps, striking his neck across the 
 arm of a chair that stood at the foot. Apparent unconsciousness for a 
 few minutes was followed by pain on swallowing, and in a few hours 
 by an emphysematous swelling of the neck which gradualK' extended 
 over the entire body from the edges of the scal]5 to the soles of the feet. 
 Severe dyspnea began about 24 hours after the accident. Occasionally 
 coughing brought up a considerable quantity of bloody mucus. Indi- 
 rect laryngeal examination was negative. Introduction of the broncho- 
 scope showed the trachea full of bubbling bloody secretions which, when 
 cleared away, showed a horizontal wound in the tracheal mucosa ex- 
 tending from the front of the trachea around the left side about the level 
 of the second ring. Below this the trachea was compressed to a scabbard 
 shape. Pushing the bronchoscope on downward completely relieved the 
 dyspnea. The bronchoscope was left in situ while a long incision was 
 made in the front of the neck. When the trachea was reached the point 
 of rupture was found to be between the first and second rings. The 
 usual vertical tracheotomic incision was made c|uite low down and a 
 long tracheal cannula inserted which relieved the breathing completely 
 on removal of the bronchoscope. The emphysema subsided in a few 
 days, the patient was decannulated without difficulty and a prompt re- 
 covery ensued. 
 
 Subcutaneous rujiture of the trachea is a very rare accident but 
 there are a number of cases scattered through the literature. The author 
 believes, however, that this is the first case observed bronchoscopically. 
 It serves to demonstrate the usefulness of the bronchoscope in the diag- 
 nosis of the exact mechanical cause of dyspnea and also demonstrates the 
 advantage elsewhere mentioned of using the bronchoscope temporarily to 
 relieve dyspnea and to furnish useful, though not essential aid in tracheo- 
 tomy.
 
 TRACHEOTOMY. 
 
 587 
 
 Acromcaalic stenosis of the larynx as shown in Fig. 438 is a rare 
 but urgent indication for tracheotomy. Glottic spasm in a case referred 
 to the author by Dr. M. 1,. Stevenson was severe at times and would 
 have been fatal without tracheotomy. The acromegalic overgrowth of 
 the larvn.x was so great that the slightest spasm would shut up the al- 
 readv narrowed "lottic chink. 
 
 Fi<;. 438. — ^.Acromegalic stenosis of the larynx in a man forty years of age. The 
 thyroid cartilage was shown by a radiograph to be enormously overgrown. The 
 massive contonr of the laryngeal landmarks corresponded to the massive facies. 
 Frequent glottic spasm, with tlu- narrowed chink, rociuind iradicotomy. 
 
 CO.\TKAI.\l)IC.\T|(INS To TK.\CI i 111 ildM ^■. 
 
 There are no contraindications to traciicolonn-. 
 
 MOUTAMTN' Ol' 'IkACII I'.dToM Y. 
 
 The mortality ui tracheotomy must be distinguished from that 
 of the lack of prom|)tness in [icrforming it. and especially from 
 that due to inetlicient after-care. \\ c fre(|uently save life when 
 tile p;iticnt is unconscious, limji and relaxed, with ihe res])iration
 
 588 TRACHKOTOMY. 
 
 entirely abolished, and the pulse nearly or quite imperceptible. In 
 the experience of all of us, many times has the result of quick work 
 seemed like quickening the dead. In one of the author's cases the heart, 
 as well as the lungs, had ceased to act, the pupils wide open and fixed, 
 according to Dr. Clarence Ingram and Dr. Thomas T. Kirk, who were 
 watching the patient. The operation shoulil be done in all jiatients ap- 
 parently dead of asphyxia. I'nder local anesthesia and at the proper 
 time, tracheotomy should be free from dangers of shock, hemorrhage, 
 or consecutive broncho-pneumonia. Between the skin and the trachea, 
 in the middle line, there is no large vessel, and no important structure. 
 There should be no more mortality from the operation, per se, than from 
 the opening of superficial abscesses by an incision of equal length. The 
 shortened route, with consequent deficiently warmed, moistened and fil- 
 tered air, does not seem to be injurious to the lower air passages. Mor- 
 tality during tracheotomy is usually caused by general anesthesia. Mor- 
 tality after tracheotomy is usually due to want of j)roper care and 
 watchfulness. Xo tracheotomic case should draw an unwatched breath 
 so long as his larynx is tightly stenosed. 
 
 Of 4:72 tracheotomies done in the clinic and elsewhere b\- Dr. Pat- 
 terson and the author, there has been a mortality of (I (1.27 per cent). 
 This includes all cases that died from any cause whatever within a week 
 of the operation. These statistics show that the ojieration is much less 
 dangerous than is generally supposed. It is to be noted that in many of 
 the cases the operation was done later than it should have been, and if 
 the series had shown even a ten per cent mortality, it would not have 
 changed the author's opinion that the operation is an entirelv safe one 
 when performed at the first indication. 
 
 INSTRf.MKNTS. 
 
 For a tracheotomy the essentials are a knife and a pair of hands. 
 Even eyesight is not essential, and the author twice has been quite suc- 
 cessful in a dark room with nothing but a knife. Such performances, 
 while life-saving and justifiable in emergencies, are to be avoided, when 
 pos.sible, by early operation with jiroper preparation. In all surgery' it 
 is wise to have the armamentarivmi as simple as possible. It is especially 
 necessary in operations which, like tracheotomy, are, in some instances, 
 extremely urgent. The following list contains all that should ever be 
 needed :
 
 TRACHEOTOMY. 
 
 589 
 
 TKACIIKOTOMY INSTRUMENTS. 
 
 Headlight. 
 Scalpels. 
 Retractors. 
 Tenaculum. 
 Trousseau dilator. 
 Hemostats. 
 Scissors. 
 
 Tracheal cannula. 
 Infiltration solution. 
 
 Curved needles. 
 Needle holder. 
 Tape (good white linen j. 
 Gauze sponges. 
 Sand bag. 
 Catgut ligatures. 
 Silk worm sutures. 
 Tubing for o.xygen tank. 
 Hypodermic syringe for local an- 
 esthesia. 
 
 'J'raclh'otdiiiic canntdac. The cannulae of the shops are very defect- 
 ive and have been the cause of death in many cases. In all the adult 
 sizes they are too short to reach the trachea after the reactionary swell- 
 ing has reached its maximum, 'i'his swelling, in some instances, doubles 
 the distance from the trachea to the skin, and thus withdraws the cannula 
 from the trachea. The thin stream of air hissing through the tracheal 
 incision deludes the nurse and the patient slowly sinks. Such cases (Fig. 
 441) have been recorded as "edema of the lungs" or "dyspnea only tem- 
 porarily relieved by tracheotomy," etc. Cases of compression and other 
 forms of tracheal stenosis require a cannula still longer and in some in- 
 stances it must reach to the bifurcation ( Fig. .\. VM and Fig. 44"-i). -A 
 fencstrum in a cannula is a great mistake. The jjatient can get plenty of 
 air past the unfenestrated cannula and tiie latter avoids the troublesome 
 uK^-rations, fniig.ations ;ind cicatricial mischief set U]) liy a fenestruni; 
 wiiicli, moreover, is seldom in position to do any good. Tapered camuilae 
 are due to a curifius misunderstanding of physics. To overcome the defi- 
 ciencies found in .-ill the canmilac in the sho[)s, the author has had made 
 by Messers I'illing a full set of cannulae (1!, b'ig. l.'>!») of sul'ticient 
 length to reach the trachea in every instance, no ni;ittcr how great the 
 swelling, e\en in cases of JAuhvig's angina. Later when the reactionary 
 swelling subsides, the space between the shield and the neck is taken up 
 Ijy additional dressiiigs (Fig. 4 11 >, ])rop])ing the shield out to the proper 
 I)oint so that the imier end of the caiunila does not turn forward and 
 press against the trachea. This e.xtra length, with proper curvature en- 
 ables the operator to fit the tube exactly to any case, and in no instance 
 is the cannula accidentally withdrawn from the tr.iclie.a with consecjuent 
 asphyxia of the patient. These tubes are made to ilie author's scale 
 (Fig. 440). H these tubes are found too long, the chances are the tra- 
 cheotomy h;is been done too high. I'or stenosis deep down beyond the 
 point where a tr;icheotomy wmnid can get below it, the long cane-shaped
 
 590 
 
 TRACHEOTO?.lY. 
 
 caiinulae shown at A, Fig. 439 are to be used. With tlie aid of the 
 bronchoscope to determine the condition, no patient should die for want 
 of air as long as he has the lung tissue to utilize it. These long can- 
 nulae may, in some instances, require cutting ofif to the proper length. 
 Under ordinary circumstances, they should never touch the carina at 
 the bifurcation of the trachea, though in some instances it is necessary 
 to extend them into one or the other bronchus, as in the case illustrated 
 in Fig. 405. The usefulness of these cannulae in thymic stenosis has 
 already been herein illustrated (Fig. 40T). A cane-shaped cannula com- 
 pletely relieving the dyspnea of compressive malignant retrosternal goitre 
 
 Fig. 4,3g. — Autlior's tracheotomic cannulae. A shows canc-shaped cannula for 
 use in intrathorac'C compressive or other stenoses. B shows fnll-curved cannula 
 for regular use. Pilots are made to fit the outer cannula; the inner cannula not 
 being inserted until after withdrawal of tlie pilot. 
 
 is shown in Fig. 442. To prevent trauma to the tracheal cartilages or 
 to the walls of the fistula, as well as to facilitate introduction when the 
 fistula tightens from cicatricial contraction ])i!ots are necessary with any 
 kind of cannula. It is unnecessary to have the pilots fenestrated and 
 hollow, because the introduction of the cannula involves but a moment 
 and it is easy for the patient to get along without breathing, or e\en to 
 hold his breath, for such a brief time. 
 
 Some patients with more or less chronic conditions which interfere 
 with inspiration, l)Ut lia\ing expiration free and easy, can be relieved 
 of the necessity of closing the tube during expiration when thev wish to 
 speak-, by the valve cannula of DeSanti. The inspiration is through the
 
 TRACIIKOTOMV. 
 
 .■)!)| 
 
 cannula in tlie ordinary way. but on expiration a valve closes oft the 
 0|)enin<j to the external air through the neck and thus the air is forced 
 through the larynx, which the patient uses for phonation. The author 
 prefers, however, the finger for temporary occlusion, and a cork for pro- 
 longed occlusion, as mentioned in conneclion with chronic larvngeal 
 stenosis. 
 
 An emergency may occur away from home when a tracheotomy has 
 to be done, and there is no cannula at hand. Under such circumstances, 
 it has been customary to recommend the suturing of the edges of the 
 
 INFANT 
 
 JVtARi 
 
 (-YflS 
 
 1JY/J5 
 
 5MALL AnULT f^OULJ 
 
 Fir,. 440. — Scale of correct size and ratliii.s of curvature of the aiitlmr's trachco- 
 tomic cannulae for the various ages. 
 
 r-? 
 
 Fig. 441. — Sclu-ma sliowing thick pad of gauze dressing, filling the space, A, 
 and used to Imld out the author's full-curved cannula when too long, prior to reac- 
 tionary swelling, and after sul)sidence of the latter. .'\t the right is shown the- man- 
 ner in whicli the ordinary cannula of the shops permits a patient to aspliy.viate, 
 though siimc air is licard passing througli the tracheal opening, H, after the cannula 
 has hcen partially withdrawn hy swelling of the tissues, T. 
 
 trachea to the skin. 'Phis is (|uite unreliable, because no such sutures can 
 be relied upon to hold the trachea very long. .\ makeshift canntila 
 formed by slitting one end of a short piece of rublier tubing and attaching 
 strong cord to each half of the slit end, m;iy be tiscd, but if ilic iiatient is 
 left in inexperienced hands, the chances are that he will asphyxiate from 
 an accident to such a contrivance. ( )f course, if he is in charge of anv- 
 one who understands spreading the tracheal wound, he will be safe if 
 closely watched; but the .sooner a proper cannula is obtained the better. 
 No hosi)ital or surgeon should be so jioorly equipped as to be compelled 
 to resort to a makeshift so hazardous to hninan life, Cannulae should
 
 -,92 
 
 TRACHEOTOMY. 
 
 never be made of aluminum. This metal is corroded by boiling, and often 
 by wound secretions. It loses its polish quickly and soon becomes very 
 rough. Hard rubber is very objectionable because it loses shape on boil- 
 ing, and its walls are so thick as to leave too little lumen. If made thin 
 it mav break. Soft rubber is open to the same objection and besides is 
 very irritating to the wound. Either sterling silver, or "German silver" 
 (neusilber) plated with pure silver should be used. 
 
 High or low tracheotomy. Which? It is \ery unfortunate that 
 there ever was made the distinction between operations above and those 
 
 Fig. 442. — Radiograph of a man of fifty years with a substernal goitrous com- 
 pression stenosis, the dyspnea of which was completely relieved by the author's 
 cane-shaped tracheotomic cannula. 
 
 below the isthmus of the thyroid gland. L'sually three separate oper- 
 ations are described under tracheotomy : namely, intercricothyroidotomy, 
 high tracheotomy, low tracheotomy. Intercricothyroidotomy should never 
 be done, unless the operator does not feel competent to do a quick tra- 
 cheotomy below the cricoid. Obviously, anything is justifiable to save 
 life, but the risk of subsecjuent stenotic troubles is verv much greater 
 after a stab operation through the cricothyroid membrane. ( Inly a small 
 cannula can be inserted. To enlarge the incision the cricoid must be cut 
 which is a thing to be avoided when possible. I'urtliermorc, one mav not 
 know the lower limits of a stenosis, which may be too low to be relieved
 
 TKAcnKiiroMV. 593 
 
 li\- the cricotliyroid operation. It is unfortunate that any distinction has 
 ever been made between high and low tracheotomy because most oper- 
 ators when a low tracheeotomy is decided upon proceed to make a low 
 incision. No wonder they consider it a difficult operation. A low in- 
 cision means a short incision and consequently they are working at a 
 great disadvantage down in a deep narrow wound full of blood. If there 
 was no division into high and low operations the trachea would always 
 be exposed high where it is superficial and followed down to the point 
 at which it is decided to open it. The inexperienced operator will find 
 it easy to lay bare ".\dam's apple." He should not incise it. but simply 
 follow it down until he comes to the first tracheal rings. If he makes 
 a long external incision, allowing himself plenty of room for the separa- 
 tion of the tissues, the trachea can be very tpnckly followed from above 
 downward, and incised at an\' point desired. If the thyroid gland is very 
 much hypertrophied, it may be necessary in some instances to cut through 
 the isthmus, retracting each lobe, though ordinarily this is not required, 
 because the isthmus is freely movable upward or downward, and room 
 enough can be obtained for the insertion of the cannula either above or 
 below. Cricothyroidotomy should not be the operation of choice. It 
 or anything else is justifiable for the saving of life but cutting through 
 the cricothyroid membrane means invasion of the subglottic region of 
 the larynx by inflammatory reaction, and this is almost certain to be 
 followed by more or less laryngeal stenosis and perichondritis. Dr. 
 Patterson and the author have noticed that a very large proportion of 
 the cases coming to our attention for the relief of post tracheotomic laryn- 
 geal stenosis has been in the cases where the operation has been done 
 through the cricothyroid membrane. Every one of these cases was an 
 emergency operation and saved the patient's life, many of them being 
 done practically in the dark and were perfectly justifiable, yet the author 
 deems it his duty to call attention to this ni;Utcr because of the prevalent 
 ojiinion among laryiigologists and general surgeons that the high tr;icheot- 
 omy, even as high as the cricothyroid membrane, is an o|ierati(in of 
 choice when quick work is needed. Division of the tluniid gland is a 
 trifling matter and should in no case influence the operator to make the 
 mistake of doing tracheotomy higher than the second ring of the trachea. 
 W lien done for subglottic edema, tlie opening should he made below the 
 third ring of the trachea, not but that a higher tracheotomy with a prop- 
 erly fitting cannula would reliive the dyspnea, but the reaction around 
 the tube, phis the subglottic inllainmation already present, is verv apt to 
 lead to stenosis. Particularly pernicious is it to incise the cricoid car- 
 tilage. Stenosis is almost certain to follow.
 
 5i)4 
 
 TRACHEOTOMY. 
 
 The author has been called upon to do a tracheotomy in a case of 
 laryngoptosis in a man .-)4 years of age affected with cancer of the larynx. 
 As almost the entire thyroid cartilage was below the sternal notch, as 
 shown in another case (Fig. 404), a subhyoid pharyngotomy was done 
 and a cane-shaped tube, Fig. 439, was inserted down through the larynx 
 into the trachea. When the cannula was removed for cleaning, the 
 growth would push out and close up the lumen within about one minute's 
 time, but by having two cannulae, as is our regular custom, and with the 
 obturator, with which these tubes are fitted, the nurse could very readily 
 make the change. All forms of trapdoor, transverse and other special 
 plans for the tracheal incision are often followed by stenosis ( Fig. 12, 
 Plate I) especially if the tube is worn for a long time. 
 
 s 
 
 Fig. 443. — Schema showing the necessity for avoiding making two tracheotomic 
 openings close together. A represents the old tracheotomic wound and B the new 
 one, leaving one or two rings in the island of cartilage, C, undivided. W hen a 
 tracheotomic cannula, D, is inserted the island, E, is pressed back into the lumen 
 of the trachea, T, resulting eventually in a permanent stenosis as shown in the 
 schematic endoscopic view, H, which represents the view down the trachea at the 
 point, E, when the tracheotomic cannula was temporarily removed for oral 
 tracheoscopy. 
 
 When necessary to do a tracheotomy below one not already healed, 
 it is necessary to work without leaving an island of cartilage between the 
 old and the new wound as will be understood by reference to Fig. 443. 
 It is not that the island of cartilage in this instance would be apt to die, 
 but a ring or two of cartilage has very little resistance to pressure and 
 one or two rings will be easily pressed in by the cannula as shown in the 
 illustration, and to become fixed there b\ inflammatory tissue as hap- 
 pened in the case from which the drawings were made. 
 
 When a tracheotomy is urgently needed before a diagnosis has been 
 made in a case suspected of being luetic, cancerous or tuberculous, it is 
 best to commence the incision high up so that the thyroid cartilage can be
 
 ■|RACIli;oTl)MY. 595 
 
 exposetl and cxaniined. \ery often in laryngeal lues ami tuberculosis 
 that has progressed so far as to need tracheotomy, periclmndrial involve- 
 ment of a plainly inflammatory character is manifest. 
 
 Asepsis. In emergencies, the saving of life may demand the dis- 
 regard of all the rules of modern surgery, not only as to the preparation 
 of the patient but even as to the sterilization of a knife and the hands. 
 It has happened to every surgeon not to see the patient until alter the 
 breathing has ceased. Except under such extreme circumstances all the 
 asej)tic precautions should be carried out with the same care as if the 
 brain. ab<lomen or thorax were to be ojiened. Such a stalcmenl may seem 
 suiiertluous to the surgeon, who, of course, expects to do all his work 
 thus, r.ut it is necessary to be especially disciplinary, as there is a nat- 
 ural tendency u]ion the [lart of nurses, internes and (ithers to permit 
 laxity because the patient coughs through the wound and. in some in- 
 stances, the surgeon must work through both mouth and wound. It 
 must be remembered, however, that the patient is more or less immune 
 to the organisms he himself harbors, while he may be extremely suscep- 
 tible to organisms, nominally and morphologically the same introduced 
 from another source. Rubber tubing of proper size for the oxygen 
 tank should be sterilized with the instruinents and one end attached by 
 tlie unsterile nurse to the tank. Then the tank should be covered with 
 wet sterile towels so that it can be handled by the sterile assistant. All 
 confusion and sejitic risks are thus a\c)ided when oxygen is needed in a 
 hurry. The autlior's tank holder illustrated nn ;i prc\inus page, is a life- 
 saving convenience. 
 
 Preparation of the patient. All the i>rccaiUions mentioned in Chap- 
 ter III must be carried out, except in great emergencies. In addition, 
 it would he wise to extract carious teeth, or have them filled and to com- 
 bat oral sepsis in all the ways mentioned. If any operation on the larvnx 
 is contemplated, it becomes absolutely imperative to get rid of every dead 
 tooth or root and to clean up and till every spot of caries. The face and 
 front of the neck should be shaven in case of a man. Tlu' skin of the 
 neck and chin should be prepared by iodin solution, used on the dry skin, 
 in the case of adults. The more tender skin of children should be 
 scrubbed with a gauze sponge, using soap and water, Idlhiwcd li\ dilute 
 alcohol. It is especially necessary to avoid causing a dermatitis bv a too 
 irritant preparatinn of the skin. In surrounding the field with towels, 
 the upper i)an uf the face should be left bare for observation. 
 
 Position of the patient and assistants for tracheotomy, and for arti- 
 ficial respiration. The jialient should be recumbent. The head of the 
 table should be lower than the fdot. The neck of the jialient should be 
 extended and rendered prdmint'ni by a sand bai; under the shoulders anil
 
 5d(i TRACHEOTOMY. 
 
 neck, not extending further toward the occiput than the prominent sev- 
 enth cervical vertebra. If this extreme extension too greatly increases 
 dyspnea, the sand bag may be moved a little more toward the head. One 
 assistant or nurse should kneel at the head of the table so as to be out of 
 the way while attending strictly to the very important duty of holding 
 the patient's head exactly in the middle line without permitting rota- 
 tion. The operator should be on the patient's right, the first assistant 
 in charge of sponges and hemostats, on the left ; the second assistant, 
 who holds" retractors, stands at the patient's head, sharing the space with 
 the nurse who kneels. The jiatient, if a child, may be wrapped in a 
 sheet to restrain the arms and legs, but it is far preferable to have both 
 legs held by a nurse and both arms held by a physician who can watch 
 the pulse at the same time. If breathing ceases the assistant at the head 
 of the table takes the two elbows of the patient for calm orderly artificial 
 respiration, 20 times a minute, compressing the chest with the patient's 
 elbows at the end of the down stroke, raising the ribs by the pull on the 
 elbows at the end of the up stroke. Thus done, the arm movements do 
 not interfere with the oxygen tubing held by the assistant at the side 
 opposite the operator. 
 
 Anesthesia for tracheotom\< should be local. General anesthesia is 
 not only unnecessary but introduces an enormous element of danger out 
 of all proportion to the anesthetic risk in the general run of surgical 
 work. The danger mav be primary from asphyxia or secondary from 
 asijiration of infected blood, pus or secretions. The cough reflex is the 
 watch-dog of the lung, and when the trachea is to be opened should be 
 preserved or stimulated, rather than drugged asleep. Aside from this, 
 general anesthesia, strange as it may seem, often renders our technic 
 more hasty and careless than local anesthesia, for the following reasons : 
 When tracheotomy is decided upon, there is usually sufficient dyspnea 
 to demand some voluntary use of the accessory muscles of respiration. 
 As complete anesthesia approaches, this voluntary action ceases, cyanosis 
 increases until the respiratory center is paralyzed from over-stimulation, 
 and the patieiit makes no further breathing effort. He never will make 
 another breathing effort unless the trachea is opened widely and on the 
 instant. For with an obstructed larynx, artificial respiration is never 
 efticient for complete o.xygenation of the blood. The trachea under these 
 circumstances is by some operators opened by a stab, rather than by an 
 incision, and it is small wonder if the percentage of mortality is almost 
 as high as of stab wounds, inflicted with homicidal intent. In the hands 
 of the most skilful and exjierienced, the incision may be badly placed : 
 (unless the author's method is followed) ; in the hands of the unskilled 
 or tlie excitable, serious accidents have ocoirred, such as the opening
 
 TR.\CUKOT(JMV. 
 
 597 
 
 of the (.■sophagus or a large vessel. A collection of tracheotomy speci- 
 mens shows inciiions at all sorts of positions and angles (Fig. 44t). 
 Tliere is no time for hemostasia ; the opening is made at the bottom 
 of a pool of blood, and the first inspiration necessarily aspirates clots, and 
 possibly pus, or infectious secretions, into the bronchioles, where it re- 
 mains, because the cough reflex is absolutely abolished by the cumulative 
 action of general anesthesia, deep cyanosis, and shock. There is, there- 
 fore, a large mortality from shock, hemorrhage, sepsis, and broncho- 
 pneumonia. How prone the profession is to underrate the dangers of 
 general anesthesia is shown by the continued succession of case reports 
 
 Fk;. 444. — Schematic illustration of faulty incisions of the traclu-a (hie to 
 faulty tfchnic. (From observations of Laurens). 
 
 ill which rcs]iirati(in has ceased on the talilc and a stab operaliim is dime. 
 ( )iir general conception of the operation is a composite picture of many 
 such instances, because we are all disjjosed to defer it until dyspnea and 
 cyanosis are extreme. Particularly fatal is the common error, permitted 
 by nearly every surgeon, of starting tracheotomy without anesthesia and 
 then giving the anesthetic after the patient has manifested evidences of 
 pain. The administration of ether, or still worse, chloroform, after the 
 subject has suffered for sometime, will hasten dangerous or fatal apnea. 
 If morphine also has previously been given, we have a combination 
 peculiarly svnergistic in killing the patient. In the dog. bronchoscopic 
 oxygen insufflation has maintained life willi ;i total absence of respiratory 
 movements for as long as IS mintites. when res]>tratory movements were 
 resumed. With the human being, however, the operator will prefer
 
 .-.98 
 
 TRACHKOTOMY. 
 
 to institute artificial respiratory movements rather than wait for tliem 
 to be spontaneously resumed. In most instances, also, inasmuch as 
 tracheotomy is to be done anyway, the surgeon, will prefer the insuf- 
 flation of oxygen into the tracheal wound, and the addition of a few 
 nitrite of amyl "pearls" to the insufflated vapor will save life. 
 
 The foregoing comments on respiratorv arrest and its treatment arc 
 made here, under the heading of anesthesia, in order to emphasize the 
 
 Fig. 445. — Schema illustrating iiitrademiatic infiltration anesthesia for tra- 
 cheotomy. The infiltration is between the lajers of the skin, not under the skin. 
 The infiltration needle, at H, is in the position of making the first injection. The 
 needle is withdrawn and inserted at the upper border of the white wheal made 
 by the first injection. Then the needle is withdrawn again and inserted at the 
 upper border of the second wheal, and so on upward until the region of the 
 thyroid cartilage is reached. The full length of the incision is thus anesthetized, 
 with no pain whatever except the single prick of the first injection. The reinser- 
 tions are at the upper edge of the anesthetized area each time. If now it is de- 
 sired to infiltrate the deeper tissues at B, one or two insertions through the anes- 
 thetized lines may be made for deep injection. Deep injections are unnecessary, 
 however, as the subdermal tissues are not sensitive. 
 
 too often unrecognized fact that it is usually the attempt at general anes- 
 thesia that precipitates apnea. 
 
 Not only is local intihratioii anesthesia safer but it is much i|uicker 
 and less troublesome. Not more than a minute is required for the in- 
 jection and the operation can follow immediately. 
 
 Local anesthesia for tracheotomy. The solution should contain a 
 niimite quantity of cocaine. Salt solution alone will cause slight anesthe- 
 sia, but the addition of cocaine, no matter how little, obtunds the nerve
 
 TRACHl-OTOMV. 599 
 
 ending l)etter than the pressure of salt solution alone. In the author's 
 clinic, a one-tenth of one per cent cocaine solution is used. The salt solu- 
 tion is sterile and cocaine tablets, which are kept constantl}- in formalde- 
 liyd \apiir. are added just before operation, the solution always being 
 freshly prepared. It is essential that the injection he intradermatic, not 
 hypodermatic. The method will he understood by reference to the 
 schema, Fig. 4-1 -"i. 'I'he author has in a great many instances dispensed 
 with even the local anesthesia in patieiUs that were not unconscious. The 
 pain was said by the patient to be trifling, as in the following instance : 
 In ,1 tracheotomy done for ])ost-typhoid laryngeal perichondritis, at the 
 Allegheny General Hospital, upon a patient referred by Dr. Mc- 
 Naugher, the operation required '^2 seconds by the watch and was done 
 without any anesthesia whatever, general or local. The patient, a woman 
 of thirty \ears, said ■"ouch" twice, and stated afterwards that the 
 operation was no more painful than the accidental pricking of one's 
 finger by a pin. 
 
 . hicstheticing a iracheotoiniccd patient. No hesitation need be 
 felt in anesthetizing a tracheotomized jiatient so far as the tracheotomic 
 wound is concerned. Such patients are far safer than one not tracheo- 
 tomized, and there is no trouble with the tongue or the tissues attached 
 to the hyoid bone falling backward and downward, obstructing breathing. 
 Tliey lal;e the anesthetic quietly. It has been necessary many times 
 for Dr. Patterson to remove tonsils from patients under treatment in the 
 clinic for laryngeal stenosis. In every instance the patient went under 
 ether quietly and was kept fully under until the operation was completed, 
 all vessels twisted and oozing stopped. The technic is simple. A fold 
 of gauze is laid (Aer the tracheotomic cannula and, if the laryngeal 
 stenosis is not complete, another over the mouth. The ether is dropped 
 upon both pieces so th;it no matter which way air is taken in, it carries 
 the ether \apor with it. It is necessary before starting to see that a 
 good stout ta])e is secvu-ely attached to the cannula and tied back of the 
 neck in the regular wa\'. < )ne assistant or nurse trained in tracheal 
 work should be stationed to gi\e undixided attention to the cannula and 
 secretions coming from it. A Trousseau dilator should be at her hand 
 should anything happiMi tn the cnuuila. If insufllation anesthesia is 
 to be used, in a tracheotomized case, it is usually preferal)le to in- 
 sert the catheter through the larynx provided there is a widely open 
 wnund for esca|)e. I 're>iun,i]ily llir l.irnyx is stenosed, but, it not, of 
 course insulllatinn tlr.nugh the laryn.x is the same as if no tracheotomy 
 had been done. 
 
 Technic. The classical descrii)tions of the ste|)S in tracheiitnniy are 
 verv f;uilt\'. The dixisinn n\ the tissues after identilicaticm, la\er bv
 
 coo TRACHKOTOMV. 
 
 layer, on a grooved director is a needless, time wasting encumbrance. 
 The skin and subcutaneous cellular tissue should be cut at the first stroke 
 of the knife. This incision should be in the median line and should ex- 
 tend from the thyroid notch to the suprasternal notch. The deeper tis- 
 sues are then divided by shallow incisions, the vessels being drawn aside 
 with retractors held by an assistant ; or seized before division as may 
 seem best. The back of the point of the knife may be used or a blunt 
 dissector if desired. The trachea is to be bared above the cricoid first and 
 then followed downward. When the entire trachea from the cricoid to 
 about the fifth ring has been bared of overlying tissues, the thyroid being 
 retracted upward or downward, all bleeding having been arrested, the 
 trachea may be incised at the desired location, hi making the tracheal 
 incision three things must lie carefully guarded against. 
 
 First, incising the posterior tracheal wall by allowing the knife to go 
 in so deeply as to cross the trachea and cut the posterior tracheo-eso- 
 phageal "party-wall." This is especially likely to happen during the 
 forward protrusion of the posterior w'all during cough, and in the small 
 trachea of infants. 
 
 Second, a badly directed incision (B, Fig. 444.). 
 Third, a double incision, from making two incisions instead of one. 
 (A, Fig. 444). If the first incision is not long enough, the knife should 
 be accurately inserted in the first incision and this incision elongated. 
 The island of cartilage between two incisions, as at A, Fig. 444, is al- 
 most certain to die and even if it does not, stenosis is apt to follow, from 
 displacement of the island and cicatricial contractions of the tracheal 
 wall. Badly directed incisions are most apt to occur from a twisted po- 
 sition of the patient's head distorting the position of the trachea, or with 
 those operators who do not follow the author's two-step finger-guided 
 method of emergency tracheotomy. 
 
 Whatever be the plan of operation, one very common error must 
 be avoided. Almost every operator is tempted to terminate his incision 
 of the trachea just as soon as he hears a hiss of air. The Trousseau di- 
 lator or a hemostat is then inserted through a very small wound, and, 
 when spread, it rips the trachea open sidewise, tearing the interannular 
 membrane. It is far better to feel the knife go through three separate 
 rings, each of which will communicate a separate and distinct sensation 
 to the finger, and they can be easily counted though not seen. This in- 
 sures a sufficiently long incision for the easy insertion of the cannula 
 without tearing the interannular membrane. For the elongation of an 
 insufficient tracheal incision tin- probe-pointed bistoury is safest, but 
 with care to avoid deep insertion the ordinary scalpel is safe. When 
 there is time, it is, of course, wise to stop all bleeding, ligating when ne-
 
 TRACHIiOTOM^-. (UH 
 
 cessary, and to lia\(.- the W'unil in-rlectly dry ami hcmostats removed 
 before the tracliea is opened. Having incised the trachea the Trousseau 
 dilator is gently used to spread the lips of the tracheal incision. Great 
 care is needed to a\oid damaging the annular cartilages or the interan- 
 nular membrane. Either accident may cause chondrial necrosis and sub- 
 sequent stenosis. If the patient has been very dyspneic. he will take a 
 deep breath, as soon as the trachea is opened, and then will cease breath- 
 ing for a few seconds. This in (mr clinic is called the "tracheotomic 
 sigh of relief" and is present in almost every previously dyspneic case, 
 especiall\- in children, and is, really, just a moment of rest and relaxation 
 after the prolonged fight for air. This apnea is readily distinguished 
 from respiratory arrest of apnea vera by the difi'erence in color of the 
 patient's cheeks. If there has been much glottic C)bstruction a quantity 
 of pus may escape. After the patient has had a few deep inspirations, 
 the cannula is inserted and the wound dressed. The upper and lower 
 ends of the incision may be drawn together with a few stitches, but as a 
 rule the incision sIkjuWI not be closed close to the cannula. Ijecause of the 
 likelihood of making a false passage when the cannula is changed. For 
 this ])urpose, a large open wound in which the trachea can lie jiromptly 
 located and its incision spread is imperative. It is necessarv for safety 
 as well as to prexent trauma to the cartilages. Patients have been 
 known to die "unrelieved l)y tracheotomy" because the interne inserted 
 the cannula down between the layers of the tissues of the neck where it 
 was left under the su]iiJOsition that it was in the trachea. Injury of the 
 cartilages or their perichondrium may result from forcing in a cannula. 
 The old advice to suture the trachea to the skin in tracheotomies for for- 
 eign bodies, instead of using a cannula, in the hope of bechic expulsion 
 of the foreign body has had a most pernicious influence, in as much as it 
 has led to the habit in various cases of such stitching which is a frequent 
 source of tracheal stenosis because of the damage done to the interannular 
 membrane and to the perichondrinn-. of the tracheal rings, i 'nly in the 
 operation of laryngostomy is such a procedure justifiable and even here 
 the author has found it best to dis])ense with it as unnecessary. Many 
 operators ele\ate the trachea with a tenaculum before incising it. In the 
 deliberate operation with a dry wound, in which the trachea can be seen, 
 this is an excellent way to fix and elevate llu- trachea for the incision. 
 The author, however, prefers to incise the undisturbed trachea. 
 
 .\s mentioned in connection with some of the cases a bronchoscope 
 in the trachea greatly facilitates a tracheotomy and, while the author 
 would not advise a preliminary lironchosco|)v as a routine procedure, 
 yet in all cases where bronchoscopy is done for conditions rei|uiring im- 
 mediate tracheotonu' the bronclioscojie sliould be k'ft in jiosition .and cut
 
 G02 TRACHEOTOMY. 
 
 down upon from the outside. Not only does the bronchoscope serve as 
 a stalT for guidance, holding the trachea up clear of the lateral danger 
 zone, but it also insures plenty of air for the patient with admixture of 
 o.xvgen if desired so that the tracheotomy can proceed in an orderly way 
 with thorough hemostasis before the trachea is opened. 
 
 In tracheotomizing patients wearing an intubation tube, it is better 
 to substitute a bronchoscope for the intubation tube before commencing 
 the tracheotomy. 
 
 KiG. 446. — Schema of practical gross anatomy to be memorized lor emergency 
 tracheotomy. The middle line is the safety line, the higher the wider. Below, the 
 sufety line narrows to the vanishing point VP. The upper limit of the safety line 
 is the thyroid notch nntil the trachea is bared, when the limit falls below the first 
 tracheal ring. In practice the two dark danger lines are pushed back with the left 
 thumb and middle finger as shown in Fig. 447, thus throwing the safety line into 
 prominence. 
 
 Emergency tracheotomy. The stabbing of the cricothyroid mem- 
 brane, or an attempted stabbing of the trachea, so long taught as an 
 emergency tracheotomy is a mistake. The author has always taught his 
 "two-stage, finger-guided'' method as safer, quicker, more efticient and 
 not likely to be followed by stenosis. To execute this promptly, re- 
 quires the operator to forget his te.xt-book anatomy and memorize the 
 schema. Fig. 4-l(). All of the important vessels and nerves are at the 
 sides of the trachea. The thumb of the left hand pushes back the ves- 
 sels and nerves on the patient's right and the middle finger of the same
 
 TRACHKOTOMV. 
 
 603 
 
 hand pushes back the left side vessels and nerves. (Fig. 447). The 
 purpose of using the middle finger is to leave the left index free for its 
 duties in the second stage. The pressure backward forces the center 
 safetv line into prominence. Xow a long incision is made from the 
 thyroid notch almost to the sternal notch, and deep enough to reach the 
 trachea. This completes the first stage. 
 
 \ 
 
 IL 
 
 \ 
 
 \ 
 
 V 
 
 V 
 
 
 
 S\tTXVO 
 
 V'- ' 
 
 Fic. 447. — Schema showing the author's tiK'thod of rapid traclieotomy. First 
 stage. The hands are drawn ungloved for the sake of clearness. The upper hand is 
 the left, of which the middle finger (M) and the thumb are used to repress the 
 sterno-cleido-mastoid muscles, the linger and thumb being close to the trachea in 
 order to press backward out of the way the carotid arteries and the jugular vein. 
 This throws the trachea forward into prominence, and one deep slashing cut will 
 incise all of the soft tissues down to the trachea. 
 
 Second stage. The entire wound is full of blood and the trachea 
 cannot be seen biU the trachea is to be found very reailily by the tip of 
 the index finger which detects the ridges of the tracheal rings feeling 
 like a wash board. The left index is moved over a little bil t(i the pa- 
 tient's left side in order that the knife shall come precisely in the middle 
 of the trachea, and the trachea is steadied by the left index so that the 
 incision can be made (jtute accurately in the middle line, notwithstanding
 
 G04 TRACHEOTOMY. 
 
 it lies buried at the bottom of a pool of blood. The head of the table 
 should he lowered, just as soon as the incision in the trachea is com- 
 pleted and a hemostat or the Trousseau dilator, if it be at hand, is used 
 to spread the lips of the tracheal wound, then the patient is turned over 
 on the side, provided the patient is breathing freely, in order that the 
 blood may run away from the wound and less of it may be aspirated. 
 In cases, however, where respiration has ceased, it is necessary to keep 
 the patient on the back so that efficient artificial respiration may be kept 
 
 Fig. 448. — Illustrating the author's method of quick tracheotomy. Second 
 stage. The fingers are drawn ungloved for the <;ake of clearness. In operating; 
 the whole wound is full of blood, and the rings of the trachea are felt with the left 
 index which is then moved slightly to the operator's left, while the knife is slid 
 down along the left index to exactlv the middle line when the trachea is incised. 
 
 up. In doing a tracheotomy after respiration has ceased, it must be re- 
 membered there will be no hissing in or out of air. Strange as it may 
 seem, many an operator has been misled into thinking he has not opened 
 the trachea by the absence of this sound which is so reliable if the pa- 
 tient is breathing. During artificial respiration, the air should hiss in 
 and out and this is the test of the efficiency of the artificial respiratory
 
 TRACIIl'OTOMY. 605 
 
 movements. Of course, if ilic wduml is [iroperly spread with the Trousseau 
 forceps or a hemostat or the cannula is inserted there is no hissing sound 
 but the air passes in and out and there are always thin-blown bubbles of 
 blood and secretion to indicate that the artificial respiration is forcing 
 the air to move in and out. The use of oxygen and amyl nitrite at this 
 stage has been referred to above. 
 
 If the operation has to be done in the dark as has happened twice 
 in the author's experience, the left index finger feels the thyroid notch 
 
 \ 
 
 Fig. 449.^Siil)stitiitc sccuiul stuKf of the author's two-stage finger-guided 
 emergency tracheotomy. This plan for the second stage is easier for many oper- 
 ators, than that shown in Fig. 448. In practice the whole wound is a pool of 
 blood, in which the trachea cannot be seen. The trachea is here shown free of 
 blood to illustrate how it is found by palpation with the left index, which also 
 serves as a guide for the knife that is slid down along the index in making the 
 tracheal incision. The autlior prcfi-r^ t)ie second-stajje position sluuvn in Fig. 448 
 
 in the first stage (Fig. I 17). The incision is guided along the promin- 
 ent central safety ridge by the fourth and fifth luigcrs of the r'n/ltt hand 
 of which the ihunib ami tlrsi \\\n \]n'^ur<. arc hdlilini; the knife. The sec- 
 ond stage is the same as if there were light. 
 
 The author has found in teaching his method of emergency tracheo- 
 tomy to others, that some ])ersons arc un;iblc to use the index freelv and 
 independently for i)alpation while fixing the trachea with the thumb and 
 the median finger. I"or them the second stage is easier executed as 
 shown in Fig. 440.
 
 ()06 TRACHEOTOMV. 
 
 RL'LKS I'OR EilERGICNCY TRACHEOTOMY. 
 
 1. A Stabbing operation is to be avoided. 
 
 2. Two incisions are better than one. 
 
 3. Press back the neck each side of tlie trachea with the thumb and 
 middle finger of the left liand to throw the median safety ridge into prom- 
 inence. 
 
 4. AJake a long deep incision from the th\roi(l notch almost to the 
 suprasternal notch. Working down in a small deep wound is diflicult. 
 This first incision should lay bare the thyroid and cricoid cartilages and 
 a few upper rings of the trachea, but" you cannot see them for blood. 
 
 5. Feel for the corrugated, wash-board-like trachea in the wound. 
 (). Incise the trachea while feeling it with the index. 
 
 T. Make the incision below the cricoid — preferably below the first 
 ring of the trachea. 
 
 S. Don't expect a hiss of air if the patient is not breathing. Slip 
 in a cannula and start artificial respiration. 
 
 9. Artificial respiration should force air in and out of cannula if 
 everything is right. 
 
 10. Amyl nitrite blown in with oxygen, is the best restorative in 
 respiratory arrest. Both may be drawn in by artificial respiration by 
 the method described in a preceding paragraph headed "Position of as- 
 sistants for tracheotomy and artificial respiration." 
 
 Al'TER-CARE l>I" TR.VCHEoTOMIZKD CASE. 
 
 A laxative, as after any other operation, is usually advisable. In 
 regard to diet, if there be no contraindication pertaining to the condition 
 for which the tracheotomy has been done, and the temperature be nor- 
 mal, there is no reason why the tracheotomized patient should not have 
 a light tray. Occasionally a patient is encountered who will have some 
 difticulty with food finding its way into the larynx, but this is exceedingly 
 unusual. Ordinarily, tracheotomized patients are able to swallow after 
 the operation just as well as before. Cleanliness of the mouth must be 
 insured by brushing the teeth after taking food, and by the frequent rins- 
 ing of the mouth with alcohol 1 part to ■") of water. .\s the cough reflex 
 is the watch dog of the lungs, antibechics, especially bromides and all the 
 opium derivatives, should be particularly forbidden. The old-fashioned 
 croup tent is of no value, and possibly is injurious to tracheotomized 
 patients. It certainly deprives them of the co])ious ventilation which is 
 necessary. There is, however, in our clinic, abundant evidence proving 
 that vaporization of compound tincture of benzoin from hot water in the 
 room is beneficial. Plenty of fresh air is absolutely essential. .-\t least
 
 TKACIllluTOMV. G07 
 
 one window shoiiid never Ijc closed in any weather, exce])t during bath- 
 ing or sponging. 
 
 A good nurse experienced in tracheal work is vital. In the author's 
 work the special tracheal nurses have saved hundreds of lives that would 
 have l)een lost under any good capable nurse with general training, but 
 without special training in tracheal work. They know how to sponge 
 away secretion before it is drawn in again. .\11 these nurses know by 
 the sound when the breathing is clear and they are competent to remove 
 the outer cannula and replace it with a clean one. Without special train- 
 ing and experience, the nurse or even the interne should not be i)ermitted 
 to change the outer cannula. The inner cannula should be removed by 
 the nurse as often as necessary. In certain cases of very thick secre- 
 tion, the cannulae mav become gummed together and occluded so much 
 that though air still comes through, it is not in sufficient quantity, and, 
 worst of all, the secretions cannot get out. Such cases often require 
 the removal of both the cannulae, every hour, for evacuation of secre- 
 tions that will not come out through the tube. In ordinary cases, how- 
 ever, the removal of the outer cannula once daily is sufficient. It is 
 most astonishing to see the statement in print, and to hear surgeons ad- 
 vise, the cleaning of the outer cannula at such intervals as a week or 
 even a month. D.'iilv cleansings of the outer cannula are imperative. 
 The nurse must be trained to dress the wound, for the dressing must be 
 done very fre(|uently, even every half-hour, if secretions are abundant. 
 The old surgical rule to disturb the wound by dressing as seldom as 
 possible, is one of the causes of the high mortality of tracheotomy under 
 routine surgical regime. Conditions here are entirely different from 
 anywhere else in the bodv. The air-infected secretions and discharges 
 must be absorbed and remo\ed by very frequent dressings, dauze, 
 wrung out of mercuric chloride. 1 : 10,000, is used in three ])ieces. 
 
 a. A large, thick, folded ]>iece to pack ardund ilie cannula. ( Xot a 
 narrow^ strip.) 
 
 b. .\ bib |iiece on the surface surrounding the stem of the can- 
 nula under the ta|ie-holders. 
 
 c. .\ filter piece to lay over the entire front of the neck. 
 
 This latter ])iece should be changed as often as soiled, even if e\ery 
 ten minutes. P.oth the filter and bib pieces should be fastened by small 
 safety pins, at the side of the neck, to the tapes which hold llic cannula. 
 Thus no bandage is needed. Duplicate cannulae for each case facilitate 
 dressings and permit of repairs. If only one caimula is available, the 
 cleaning is apt to he done hastily resulting in imperfect cleansing or in 
 damage to the cannula. Dinged edges are certain to cause erosions and 
 cicatrices. Tracheotomic cannulae when worn lor a long lime, no mat-
 
 f;os 
 
 TRACHEOTOMY. 
 
 ter of how good construction, nor how carefully cleaned, become dam- 
 aged and should be carefully watched for beginning breakage. The most 
 common accident is the breaking off of the tube from the tape holder 
 with resultant escape of the tube down the trachea. Before the days of 
 bronchoscopy this was a very grave accident. Hunt (Bib. 211) re- 
 ports a very interesting bronchoscopic removal of a very large cannular 
 tube. Coolidge removed one in ISiili, one of the earliest bronchoscopies. 
 
 Fig. 450. — Schematic illustration of Dr. Ellen J. Patterson's method ot attach- 
 ing the tapes to tracheotomic cannulae. Near the end, A, a slit is cut in the tape 
 with scissors, the tape heing folded for cutting. The end. A, is then passed 
 through the slot in the tape plate from the under side as shown at D. The end, 
 B, is then pulled through the slit in the tape, and drawn taut as shown at C. The 
 tape must be of pood strong linen and must not be less than 19 mm. (three- 
 fourths inch) wide. 
 
 Man_\- parts of the cannulae have been removed since, and while almost 
 all have Ijeen successful, yet the patient may asphyxiate, and every care 
 should ])e taken to see that the cannulae are in perfect condition. Can- 
 nulae. especially inner ones, re(|uire careful cleaning. It is (|uite common 
 to find nurses, unless specially taught, failing to get otu all the inucus 
 from the central part of the tube. This is boiled in place, and hence 
 the canntila gets obstructed soon after replacing. The pipe cleaners sold 
 by tobacconists are excellent for cleaning tubes, two or more being used 
 at once, in a bundle.
 
 TRACHEOTOMY. 609 
 
 The cannula may be obstructed by exuberant granulations. These 
 should be removed with forceps, which method is preferal)le to caustics 
 in our experience. Tracheal papillomata may obstruct the cannula and 
 may appear in great abundance in the trachea after they are removed 
 from the larynx. They should be searched for with a small broncho- 
 scope and removed with forceps and pure alcohol may then be applied 
 carefully to the points from which they spring, being especially careful 
 not to allow any to get down into the trachea. Obstruction of the can- 
 nula by membrane in diphtheritic cases is not at all uncommon, and re- 
 quires prompt action on the part of the nurse. 
 
 The tapes are attached to the cannula before the caniuila is intro- 
 duced. The manner of attaching the tapes to the tube, clearly illustrated 
 in Fig. 4.'J0, has been in constant use in our clinic for many years with 
 great satisfaction. .\ jiilot should always be used to prevent trauma, and 
 for the first week the Trousseau dilator must be used to spread the 
 tracheal incision to avoid trauma to the cartilages. The little bent wire 
 loops that are usually attached to the inner cannula, are very much in 
 the way in sponging away the secretions, and considerable practice on 
 the part of the nurse is necessary in order quickly to wipe clean the 
 coughed out secretions from between these loops before the secretions 
 are drawn in again. The wire loops may be done away with and the 
 finger nail used to withdraw the inner cannula. But if this is done, 
 there may be serious delay in remo\ing the inner cannula in case it 
 becomes obstructed, and as this might be such a serious matter, the 
 author has preferred to leave on the wire loops and to train the nurses 
 to \\i|n.' between them. There should be no Ijreathing sound andilile 
 with a properly fitted cannula. The classical "stridor serraticus" which 
 used to be considered as properly pertaining to the cannulated patient 
 is noticeable by its absence with a proper cannula, exce])t, of course, 
 when the cannula is obstructed with secretion or when the patient 
 coughs. .-X sterile "tracheotomy tray" should \k- in the room of every 
 tracheotomized i)atient. 
 
 .'\ tracheotomy tray should contain : 
 
 Tracheal canimla. duiilicate of one ])atient wears. 
 
 Trousseau dilator. 
 
 Dressing forceps. 
 
 Scissors. 
 
 Sterile vaseline. 
 
 Tape. 
 
 Gauze sponges. 
 
 Gauze sr|uares. 
 
 Sol. mercin-ic biclilnride -1 - lo iioO.
 
 610 TRACHKOTOMY. 
 
 In the after care of tracheotomized cases, it is necessary to remem- 
 ber that edema of the hnigs, pneumonia, broncho-pneumonia and fatal 
 bronchitis are the rarest of complications following tracheotomy. Many 
 patients die from unrecognized purely mechanical conditions and very 
 few from the just-mentioned diseases. When a patient is not doing 
 well, the trachea should be examined. It is necessary to remember that 
 dvspnea or obstructed breathing or simple "sinking of the patient" ap- 
 parently of exhaustion and without dyspnea may be due ti) 
 
 (a) Obstruction of the cannula by dried, cooked, thick or even 
 thin secretion. 
 
 (b) Obstruction of the trachea itself by the same substances below 
 the caniuila. 
 
 (c) Obstruction of the trachea by compression. 
 
 (d) Cannula not reaching into the trachea. 
 
 , Decannulafion. The cannula should not be abandoned until the 
 patient can sleep quietly with the outer cannula in place, the inner 
 cannula being removed and a tight fitting cork placed in the outer orifice 
 of the outer cannula. If the patient cannot do this, the larynx is stenosed 
 and special work will be needed to decannulate the patient as will be 
 explained in a future chapter. When the cannula is no longer needed 
 the wound must be packed so as to heal from the bottom outward. 
 There will never be cartilaginous union, but fibrous union of the divided 
 edges of the tracheal incision must be complete before the outer tissues 
 are allowed to close. Plealing cartilage is prone to be associated with 
 exuberant granulations aufi these may occlude the trachea and require 
 a new tracheotomy for dyspnea. A number of such cases have been 
 sent to the author, who located the trouble bronchoscopicall\'. ( See Fig. 
 12, Plate II, in the earlier volume. Bib. 'H>i).) In order to keep the 
 wound open, it is necessary to pack it firmly, not with a strip of gauze 
 an end of which might get into the trachea, but with a small firm roll of 
 gauze wedged into the depression corresponding to the wound, which 
 latter is first overlaid with a large piece of gauze that covers the entire 
 front of the neck, including the wound, as will be illustrated in connec- 
 tion with thyrotomy. 
 
 Cor.ipUcaiions. Erysipelas, diphtheritic and severe pyogenic infec- 
 tions of the wound ought to he exceedingly rare if a very careful aseptic 
 technic is carried out. Even streptococcic and pneumococcic infections 
 from the air passages in previously purulent cases, are exceedingly in- 
 frecjuent if the author's method of frequent dressings, (every one to 
 three hours), be followed, especially when the dressings are wrung out 
 of one to ten thousand bichloride solution. Tracheal ulcerations from 
 pressure of the cannula are exceedingly rare if the cannula fit properly.
 
 TRACHEOTOMY. 611 
 
 .^uch ulcerations may be followed by cicatricial contractions resulting in 
 stenosis. The most serious of all complications is necrosis of more or 
 less of the cartilaginous rings, and this is sure to result in more or less 
 stenosis. This comjilication is best avoided by the directions given for 
 preserving the perichondrium and the inter-annular membrane, and by 
 careful selection of the caimida to fit the patient. ( )pen air treatment 
 is one of the best projihylactic and therapeutic measures for all infective 
 com])lications. 
 
 Hemorrhage after tracheotom_\- may occur especially iluring the 
 straining of coughing A vein or artery may lose its ligature, but as it 
 is exceedingly rarely that vessels of any size are cut through, it is not 
 usually a serious matter, unless a great quantity of blood should get down 
 into the air passages. The best way to arrest it is, of course, to open 
 up the wound and search for the bleeding points with hemostats. If the 
 vessels have retracted into the soft tissues, it may take some little search, 
 but they can always be found. Ordinarily, subcutaneous emphysema fol- 
 lowing tracheotomy is of little conse(|uence and soon disappears. It is 
 much more likely to appear if the tracheal wound is sutured, but oc- 
 casionally hapi)ens, though rarely, with wounds packed open.
 
 CHAPTER XXXVIII . 
 
 Chronic Stenosis of the Larynx and Trachea.* 
 
 Chronic stenosis almost invariably comes to the surgeon in the 
 form of a tracheotomized or intubated patient who cannot abandon his 
 cannula or intubation tube because of the larj-ngeal stenosis. There- 
 fore, it will contribute to clearness to consider the subject from this 
 viewpoint. The different forms of laryngeal stenosis associated with 
 difficult decannulation or extubation may be classified into the follow- 
 ing types : 
 
 1. Panic. 
 
 2. Spasmodic. 
 
 3. Paralytic. 
 
 4. Ankylotic (arytenoid). 
 
 5. Neoplastic. 
 
 G. Hyperplastic. 
 7. Cicatricial. 
 
 (a) Loss of cartilage. 
 
 (b) Loss of muscular tissue. 
 
 (c) Fibrous. 
 
 Panic. Breathing through the neck with a properly placed tracheo- 
 tomic cannula is so much easier than breathing through the mouth that, 
 once the patient becomes accustomed to tracheotomic breathing, for 
 quite a while he does not feel that he is getting enough air through the 
 mouth, even though the larynx is perfectly patulous. In addition to 
 this there is a "nerve cell habit" arising from previous experience with 
 the stenosis that terrorizes the patient, especially a child, the moment he 
 feels the slightest dyspnea. In children crying tends to increase stenosis 
 (by disturbance of resjjiratory rh\thm and by venous engorgement), 
 and fright is very apt to do so in either adults or children. Glottic 
 spasm may or may not contribute. .Ml these things taken together 
 
 ♦lievised, with additions, from thie autlior's paper read l>efore the American 
 Laryngologrical Association, 1913. (Bib. 26:i. Interesting discussion.)
 
 CHRONIC STENOSIS OF TIIIC LARYNX AND TRACIIKA. 613 
 
 may be called "panic"' and constitute cjuite a formidable obstacle to 
 decannulation even where there is no real stenosis of the larynx. 
 
 Spasm. Spasmodic stenosis may be associated with ])anic, or may 
 be excited by subglottic inflammation. It is usually overcome by the 
 same means as those suggested for ])anic, together with the treatment of 
 the inflammatory condition that may be present. Doubtless one of the 
 chief causes of adductor spasm is the prolonged wearing of an intubation 
 tube, especially a large one, which ])revents activity of the adductors, and 
 of the abductors ; because the action of these two sets of muscles is re- 
 ciprocal, and the normal balance is, of course, interfered with by the 
 presence of an intubation tube for a long period. Three methods of treat- 
 ment may be used in these cases to get the patient permanently extubated. 
 1. Replacing the intubation tube with a special one, which has a very 
 narrow neck with a long anteroposterior lumen in order to allow free 
 glottic action for a time, until muscle balance is restored. 2. In a few 
 cases of not very severe type it is possible to get them well by a patient 
 extubation with replacement as soon as the child begins to get blue. This 
 requires a facile intubator who has plenty of confidence in his ability to 
 slip in the intubation tube promptly and without trauma. This method 
 will not succeed in a violently spasmodic type, where the symptoms are 
 so urgent and severe that the tube can be left out for only a few seconds. 
 But in the less severe ty])e of cases it is (juite often successful. 3. 
 Tracheotomy for extubation is the C|uickest method of cure in purely 
 spasmodic cases without organic stenosis. The wearing of a tracheotomic 
 cannula for a week or two will permit the restoration of muscle balance, 
 and by corking the cannula with a slotted cork, as elsewhere herein men- 
 tioned, the child can be gradually weaned away from the cannula, and 
 thus ]5ermanently extubated and decannulated. 
 
 Paralysis, liilateral laryngeal paralysis causes a severe stenosis of 
 the larynx. ])ro\ided the paralysis is not cadaveric. In cadaveric paralysis 
 there is usually sufficient breathing space, and this has led to operative 
 nerve division to relieve stenosis. The author agrees with Charles H. 
 Knight that nerve <li\isi()n has been a faihu'e, but llie author has thought 
 that nerve excision might yield better results. In ibe one case in which 
 the author tried nerve excision, it was a failure In decannulation in 
 paralytic larynge.'il stenosis three methods of trealnienl may be fi}lloued. 
 Cordectemy has yielded good results in rare instances, the cords being 
 excised either by thyrotomy or endolaryngeally. The author had one suc- 
 cess after evisceration of tin' larynx endoscopically by the direct method. 
 The results of tbyrotoniic evisceration (Fig. I'll ) are absolutely ideal in 
 cases where there are no lesions other than the bilateral paralysis. 
 Formerly, when it was thought that excision of the cords meant perma-
 
 614 CHRONIC STF.XOSIS OF TIIK LARVXX AND TRACHEA. 
 
 nent loss of voice one might hesitate to recommend evisceration. In two 
 cases operated upon by the author a fairly loud, though very rough 
 phonation, mostly in a monotone, was obtained by both the patients. It 
 was a good useful \oice. in both instances, though, of course, it did not 
 have the flexibiltiy that we see after thyrotomy for conditions in which 
 there is unimpaired mobility of the arytenoid joints. In both of these 
 cases, however, the author did a careful dissection, taking out all the soft 
 tissues and not simply the cords alone. The technic was the same as for 
 thyrotomy ( q. v.) except that the perichondrium was not removed, and 
 the dissection was done on both sides instead of onlv one. l^oth patients 
 were permanently decannulated. Great care is necessary to make sure 
 that all of the sub-glottic tissue is dissected out. Of course the operation 
 is only to be recommended when the paralysis is unassociated with essen- 
 tiall\- fatal conditions, such as aneurj'sm and malignant mediastinal 
 tumors. George L. Richards reports a case in which spontaneous recov- 
 
 1.1 
 
 Fig. 451. — Schematic representation of evisceration of the larynx for chronic 
 paralytic stenosis. The dotted line represents the line of dissection, endoscopic or 
 thyrotomic. 
 
 ery from a laryngeal paralysis occurred, but that was in a chilil and was 
 for a short time only. As a rule, it may be said that when bilateral paraly- 
 sis remains twelve months it will never be followed by recovery, because 
 of muscle atrophy or joint stiffening. Therefore, the operation is justifi- 
 alile, if the patient wishes to be decannulated and considers some impair- 
 ment of voice more than outbalanced by the getting rid <if the cannula and 
 by being made absolutely safe from asphyxia. It is rather appalling to 
 note the number of patients with Ijilateral laryngeal paralysis that have 
 died as a result of accident to the intubation tube or cannula. In bilateral 
 recurrent j)aralysis of recent occurrence it may be worth while to attempt 
 suturing the recurrent to the pneumogastric, provided the paralysis is re- 
 cent, even if it is not peripheral. Monolateral paralysis does not usually 
 cause sufficient dyspnea to call for a tracheotomy, but it is worthy of note 
 that excision of a scar and suture of the recurrent laryngeal after injtiry 
 has been successful in restoring motion to one cord (J. Shelton Horsley 
 and Clifton IM. ]\liller).
 
 CHRONIC STKNOSIS 01' THI': I,AK^■^■^■ AND TRACHEA. CIS 
 
 Anhylosis. Ililatcral ankylolic coiulitiuns of the cricoarytenoid joints 
 may prevent decannulation until the laryngeal stenosis is relieved. In one 
 case of this kind, thyrotomic exisceration of the larynx, as mentioned 
 above for paralysis, completely cured the stenosis in a man forty years 
 of age. (Fig. 4--)l.) ( )f course, evisceration is not to be advised, except 
 in such cases as have remained rigid for a period of twelve months or 
 more, and it is not meant to include the fixation that is associated with 
 malignant, tuberculous or k-utic intillrations. Endoscopic evisceration 
 (Fig. I."i2 ) is ]ireferable to thyrotomic evisceration. (For tcchnic of endo- 
 scopic evisceration, see Chapter \'TI.) 
 
 Neoplasms. l.)ecannul;uion in neoplastic cases will, of course, de- 
 pend, so far as stenosis is concerned, upon the nature of the growth and 
 its curability. In malignant conditions after tliyrotomy, stenosis prac- 
 tically never occurs. After hemilaryngectomy. stenosis may follow from 
 a flaccid ccmdition of the side wall of the larynx, or there may be a cica- 
 tricial contraction diminishing the stenosis. .-\s a rule, in these cases, the 
 author believes the best treatment is continuous dilatation from the pro- 
 longed wearing of a large intubation tube, though it is better to defer 
 inlubational dilatation until quite certain that the malignancy is not going 
 to recur; becavise if the malignancy recur re-operation for malignancy can 
 be so planned as to take care of the stenosis, by evisceration of the normal 
 half of the larynx. In cases of stenosis associated with benign tumors 
 other than iiapillomala. decannulation rarely presents difificulties. The 
 removal of the tumor usually restores the laryngeal lumen. 
 
 Papilloiiiata. Tapillomata ])resent c|uite a ditTereut ijroblem, inas- 
 much as the growths persistently recur, though, of course, unlike malig- 
 nancy, they do not infiltrate. Their remo\al usually restores the lumen 
 and the patient may lie thus readily decaiuuilated : but recurrence must 
 be carefully watched for and removed before the stenotic stage is reached. 
 As a rule, it is better to wait for ;il least six months after discontinuance 
 of recurrence before begimiing decannulation as hereafter described. If 
 |)apillomata have been carefully removed, and no injury has been done to 
 the motor area of the larynx, there will be no cicatricial stenosis. I'n- 
 fortunately, (|uite a number of cases are seen in which direct or indirect 
 operations ha\e removed masses of normal tissue, which has been fol- 
 lowed by severe cicatricial stenosis, in some instances, the motor area 
 has been damaged .so as to lead to ankylotic stenosis. 
 
 Compression stenoses of the trachco. Peritracheal neoplasms oc- 
 casionally cause compression sli-uosis as do also hyperlro|)hy i)f the lh_\- 
 mus and thyroid glands. Decannulation in a thymic compression ((|. \'. ) 
 case is \ery readily accomplished by either tii\niopexy or a subtotal thy- 
 mcct(]niy, .\ struma can be de.-ill with b\- the usual well known methods.
 
 616 CHROXIC STENOSIS OF THE I.ARYNX AND TRACHEA. 
 
 Hyl'er plastic and cicatricial chronic stenoses preventing decannula- 
 tion may be classified etiologically as follows : 
 
 1. Tuberculosis. 
 
 2. Lues. 
 
 3. Scleroma. 
 
 4. Acute infectious diseases. 
 
 (a) Diphtheria. 
 
 (b) Typhoid Fever. 
 
 (c) Scarletina. 
 
 (d) Measles. 
 
 (e) Whooping Cough. 
 
 5. Decubitus. 
 
 (a) Cannular. 
 
 (b) Tubal. 
 
 6. Trauma. 
 
 (a) Tracheotomic. 
 
 (b) Intubational. 
 
 (c) Operative. 
 
 (d) Suicidal and homicidal. 
 
 (e) Accidental (by foreign bodies, external 
 
 \iolence, bullets, etc.) 
 
 Most of the organic conditions, outside of the paralytic and neoplas- 
 tic forms, are almost all the result of inflammation, often with ulceration 
 and the secondary tissue changes. In the infective granulomata, such as 
 lues and tuberculosis, and in the acute infectious diseases, it is practically 
 always the mixed infections from oral sepsis running riot that do the 
 harm. The chief exception to this is diphtheria, which in many cases is 
 distinctly a necrotic process, wherein the replacement of the lost tissue by 
 cicatricial tissue causes the stenosis either by cicatricial contraction or by 
 the bulk of the newly formed inflammatory infiltrate or of pus collec- 
 tions. Typhoid fever ((]. v.) is also associated with necrotic processes 
 in some instances. 
 
 Tuberculosis. In the rare cases in which laryngeal tuberculosis of 
 such severe type as to demand tracheotomy is cured, decannulation usual- 
 ly presents little difficulty after the infiltrations are reduced. Should 
 cicatricial stenosis from ulceration persist, it is, of course, to be treated 
 in the same way as cicatrices in other cases, by laryngostomy. The author 
 has seen but a single case of this kind. In the non-cicatricial forms, 
 which arc relatively common, laryngostomy is not necessary, and direct 
 ajjplication of the cautery will give such a degree of reduction of infiltra- 
 tion as to give an ample lumen.
 
 CHRONIC STENOSIS 01" TIIK LAKVNX AND TRACHKA. G17 
 
 L"cs. Swain reports a case of luetic immobility of both cords in 
 which the intermittent wearing of an intubation tube gained suf¥icient 
 lumen in the larj-nx for respiration until general medication cured the 
 patient. I'nder the careful watchfulness of Dr. Sw-ain, such a procedure 
 was safe, but as a rule patients are far safer with a tracheotomy. Luetic 
 cicatrices are proverbially prone to return, and are particularly vicious in 
 contraction. Prolonged stretching with oversized intubation tubes follow- 
 ing either incision with the galvano-cautery or e.xcision with cutting for- 
 ceps is sometimes successful. biU usually laryngostomy is required. In 
 those old cases of chronic luetic fibrosis, which are, in a sense, paraluetic 
 conditions little, if at all. amenable to the older methods of medication, 
 salvarsan has accomplished wonders. It has even been claimed that 
 cicatrices of luetic origin have been benefited. It would seem, however, 
 that in such cases there must have been an underlying fibrosis of the na- 
 ture of a luetic lesion, and not purely and simply a cicatricial condition 
 following such a lesion. Scar tissue is scar tissue, regardless of what 
 prf)(luceil it, and we must rely upon laryngostomy for the cure of most 
 of these scarred conditions. 
 
 Scleroma. Dr. Emil Mayer recommends the use of radiotherapy in 
 the treatment of scleroma. If the stenosis is severe, doubtless it would 
 be well to open the larynx externally and keep it open as in laryngostomy, 
 so that the applications of the ray could be direct to the scleromatous 
 tissue. Previously the results of treatment of scleroma were unsatis- 
 factory, and those unamenable to ray treatment probably constitute the 
 onlv cases of chronic laryngeal stenosis in which decannulation is impos- 
 sible. 
 
 Diphtheria. Diphtheritic cases may be of the panic, spasmodic or, 
 rarely, the paralytic types ; but more often the stenosis is of either the 
 hypertrophic or cicatricial forms. After intubation, especially if i)ro- 
 longed, there may be a hypertrophic condition, which is manifest in two 
 ways: 1. An edematous condition of the up])er orifice of the larynx, 
 usually worse anteriorly around the base of the epiglottis but also in 
 some instances extending backward over the glossoepiglottic fold and the 
 ventricular band, either or both. (Fig. 11. Plate I.) To this form, the 
 author has giver, the name supraglottic hypertro])hy. It resembles some- 
 what the ordinary acute laryngeal edema, exce])t that it is firmer, seems 
 to be chiefly anteriorly, is more sharply limited than the latter lesion 
 usually is, and it has somewhat of a tendency to overhang and occlude 
 inspiration more than ex[)iralion. The supraglottic hypertrophy the 
 author has found, in some instances, to be due to the wearing of an 
 intubation tube which has a sharj) angle at its upper anterior edge. In 
 one instance, the IuIjc was smootin and rounded in this position, but was
 
 018 CHKOXIC STENOSIS ()!■ THIC LARYNX AND TRACHEA. 
 
 entirelv too thick in the neck for the age of the child. Where these or 
 any other defects in the tulie are suspected of being responsil)le for the 
 trouble, it is wise to change ilic tul)e for one of correct model and size 
 and await results before attempting any more radical treatment, though 
 local applications of the galvano-cautery can be made while testing out 
 the effect of a correct tube. Excessive polypoid supraglottic hypertrophy 
 should be excised. (Fig. 11. Plate I.) The infraglottic type is usually 
 bilateral. (Fig. 87.) The masses encroach upon the lumen from each 
 side like hypertrophic turbinals. Patients with either the supraglottic or 
 infraglottic forms, if intubated, should be tracheotomized and the in- 
 tubation tube thus dispensed with. They arc very much safer with a 
 tracheotomic cannula in place than intubated. In the infraglottic type of 
 hypertroph}-, the most wonderful results have followed the author's 
 method of direct applications of the galvano-cautery ( q. v.) With care 
 there is no need of injuring any of the muscles or either of the crico- 
 arytenoid joints. The author and Dr. fallen J. Patterson have never yet 
 failed to cure a subglottic hypertrophic post-diphtheritic stenosis by the 
 galvanocauterant treatment. 
 
 In the cicatricial type of post-diphtheritic stenosis the tibrous tissue 
 may take many forms. In some cases there is a band running across the 
 larynx from one side to the other, it may be between the two ventri- 
 cular liands, between the two cords, or from one band to the opposite 
 cord, or to the same cord of the same side. Occasionally tlie cicatrix is 
 in the form of a funnel with a minute opening at the bottom of the fun- 
 nel. (Fig. 1, Plate 1.) In some instances there is a web anteriorly (Fig. 
 4, Plate I), which very much diminishes the air space and may interfere 
 with phonation or may not, depending on the degree of approximation 
 possible. In two instances the author has seen a cicatricial mass between 
 the arytenoids posteriorly with ankylosis of both joints, leaving only a 
 very small opening close to the anterior commissure. This is unusual. 
 More frequently the opening is somewhere in the posterior two-thirds. 
 The management of the panic and spasmodic types of post-diphtheritic 
 stenosis has been previously herein considered. The cicatricial forms 
 require dilatator}- intuliation or laryngostomv or both. (q. v.) 
 
 Typhoid fever. About ten years ago, when typhoid fever was very 
 prevalent in Pittsburgh, the author made an investigation of the laryngeal 
 complications (Am. Journal Med. Sciences, Nov. 190.")) with the aid of 
 Dr. Ralph Duffy and Dr. Joseph H. Barach. It was found that the ulcer- 
 ative lesions in the larynx were practically always the result of a mixed 
 infection, and in some instances they were due to thrombosis of a small 
 vessel with subsequent necrosis. \\ hen the ulcerative processes reached 
 the perichondrium cicatricial stenosis was almost certain to follow, and
 
 CTIKONIC STENOSIS 01" TTIK I.ARVNX AND TRACHEA. 
 
 Gill 
 
 ijractically all ot" the cases with perichmulritis resulted in necrosis and 
 reeiuired tracheotomy for acute edematous stenosis. The decannulation 
 of these cases .vas chiefly by prolonged intuljation, with siiecial intuba- 
 tion tubes, the author's T-shaped cannula, and in some instances, laryn- 
 gostoniy. The detailed results have been previously reported. ( I'.ib. 'US 
 and 2.-)'J ). Ankylotic and paralytic post tyj)h(jid stenoses were treated 
 with excellent results liy Dr. Kllen j. Patterson and the author, by endo- 
 scopic evisceration of the larynx. ((|. v.) (See also Figs. 8() and 453.) 
 Scarlatina may be followed by acute laryngeal stenosis, due to in- 
 fection with either stre])ococcic or oth.er jiyogenic organisms. There may 
 be cellulitus of the neck, choridritus and necrosis, but these are rare. In 
 any event, the stenosis following is cicatricial and is handled like anv 
 other cicatricial stenoses. 
 
 Fu;, 452. — Post-tyiihoid .-mkylotic stenosis. A, iiililtraticm of aryepii^loltic folds 
 and arytenoid region with li.xaiion of cricoar\ tonoid articnhitiims. B, three 
 months later; inliltration disappeared, arytenoids immoliilc. C, twelve 
 months later; tissues shrunken hut no ahduction possible. D, result of endoscopic 
 evisceration, six months after decannulation. Xo mobility and no tendency to 
 formation of an adventitious cord in the absence of a motile arytenoid. 
 
 Trauma. Occasionally foreign bodies, by a prolonged sojourn may 
 ulcerate through from tlie esojihagus into the trachea, causing cicatricial 
 stenosis as elsewhere herein mentioned. Trauma, during the ])r<ice(hire 
 of intubation, is very often charged with producing stenosis, which pre- 
 vents the abandonment of the intubation tube. In the author's experi- 
 ence, this is excccdinylv rare, the stenosis lieing diU' In other causes inci- 
 dental to the disease for which the intubation is done. Diphtheria is 
 essentially a necrotic ])rocess, that with or without intubation is apt to 
 lea\e ■•icatricial •■.tenosis. and. ni tlie author's experience, stenosis has fol- 
 lowed tr.''.cheotomy about as fre(|uentiy as intubation. Decubitus is fre- 
 quently referred to as though it were the presence of the tube that caused 
 ulceratidU. It is dcjubtful if a pniperlv litling intnb;ition lube will cause 
 any ulceration, no matter how iung it remains if it be free from rough- 
 ness or sharp edges, and is removed sul'ticientlv frei|uentlv to be cleaned. 
 A lube left ill l:io long mav be crusted with concretions that will iiroducc
 
 620 CHRONIC STENOSIS OF THE I.ARYNN AND TRACHEA. 
 
 ulceration. Lynah reports fatal trauma from intubation tubes forced 
 into the tissues of the neck by unskilled attempts at intubation. Tracheo- 
 tomy is so commonly postponed until the very last moment that it is most 
 frequently an emergency operation. Consequently the incision in the 
 trachea is often very much misplaced, running off at an angle, or even 
 slicing the side ofif the trachea like a slab from a log. Often also dam- 
 age is done with dilating forceps tearing through the interannular tissue, 
 and at times even denuding the cartilage of the rings. Then again, for 
 one reason or another, various newly devised incisions with trap doors 
 and even with excisions of cartilage are tried experimentally, nearly al- 
 ways resulting m more or less stenosis after cicatricial contractions set 
 in. (Fig. 12 and 1(1, Plate I, and Fig. 443.) Undoubtedly in the inser- 
 tion of a trachcotomic cannula, especially if it be done without a pilot, 
 it is very easy to denude the posterior wall of the trachea, and in time 
 an ulceration may follow, which may be attributed to decubitus, when 
 really it is simply oft-repeated trauma. A properly fitted trachcotomic 
 cannula should not produce decubitus, or even erosion of the epithelium. 
 Neglect of cleanliness produces diseased granulations that result in build- 
 ing up a great mass of inflammatory infiltrate, which later becomes 
 fibrous, and a thick dense scar results. (Operations for malignancy and 
 other conditions in the neighborhood of the trachea and larynx may cause 
 stenosis, and in one instance the author has seen a compression stenosis 
 in the trachea due to cicatricial contraction following a burn with a band 
 of hot iron externally on the neck. 
 
 Attempted suicide occasionally results in serious damage to the 
 cartilage, and if very careful work is not done, stenosis may follow. 
 Usually an intubation tube should be worn in the larynx and trachea un- 
 til the wound inflicted in attempted suicide has healed. 
 
 Abscesses have been the cause of the stenosis in two cases sent to 
 the author for decannulation. Xecrosis of the cricoid cartilage during 
 pneumonia, in one case, was the fundamental process. In the other 
 direct study discovered an old abscess in the "party wall." Treatment 
 of these conditions by the direct method is easy, once the lesion is located 
 but the location is not always easily determined unless careful search is 
 made. If the original cords are destroyed by the abscess, good adventiti- 
 ous bands can be formed in some cases from the resultant scar tissue 
 as elsewhere herein explained. 
 
 Treatment of cicatricial stenosis. In deciding the method of treat- 
 ment to be used in a given case, it is very essential that a very careful 
 bronchoscopic and direct laryngoscopic examination be made in addition 
 to ordinary indirect laryngoscopy, \\ith the direct laryngoscope and the 
 esophageal speculum the party wall can be accurately studied. In many
 
 CHUOXIC STEXOSIS 01' THE LARYNX AND TRACHEA. G21 
 
 instances granulation tissue about the tracheal cannula should he removed 
 in order to determine to what extent this is a factor in the stenosis. Oc- 
 casionally a case is encountered where the nature of the stenosis which 
 has required a tracheotomy has not been determined, and where it is 
 exceedingly difficult to determine it. In some instances there is nothing 
 to be seen but a large, smooth, rounded swelling on all sides of the 
 larynx, suggesting tuberculosis, lues, or an inflammatory condition. In 
 such instances, before planning a procedure, it was at one time necessary 
 to do an exploratory thyrotomy, but since the development of the direct 
 method where amijle specimens can be accurately taken, it is possible 
 to make an accurate diagnosis of conditions, if not of their etiology, in 
 every instance. A sliding punch forceps should be used for this purpose, 
 the distal end being inserted between the cords and a large mass of the 
 tissue removed, always avoiding injury to the cricoarytenoid joints. 
 
 The treatment of all the different forms of stenosis is much the same 
 if cicatrices have formed. In cases which have not yet cicatrized, cica- 
 trization must be brought about liy excision of exuberant granulations 
 and argyrol api)lications, as the very first step. The fungating granula- 
 tions from necrotic cartilage are particularly troublesome. In these 
 cases the (|uickcst and best method is to lay open the larvnx and trachea 
 to facilitate drainage and resorcin apjilications. Such cases recjuire laryn- 
 gostomy anyway, but dilatation must not be commenced until the cartilag- 
 inous necrosis has ceased and healing is complete. In intubated cases 
 which show a tendency t(j close within a few hours or a few days after 
 the removal of the intubation tube, ii is safer to do a tracheotomy and 
 remove the intubation tnbf. In a h-w instances, however, it mav be 
 well to try intubalional dilatation. Webs and bands of cicatricial tissue 
 should be excisetl. Should intiibational dilatation fail, laryngostomy will 
 cure almost e\ery case. The treatment is jn-olonged but not painful and, 
 by the authorV method, the patient has the use of the whispered voice 
 during the entire treatment.
 
 CHAPTER XXXIX. 
 
 Intubational Dilatation of Chronic 
 Laryngeal Stenoses. 
 
 Intubational dilatation of chronic stenoses is advisable as the first 
 means of treatment of all post inflammatory chronic laryngeal stenoses. 
 It is also indicated when there is a slight recurrence of stenosis after ap- 
 parent cure by larvngostomy. It is best adapted to comparatively recent 
 cases in which there is not a thick deposit of cicatricial tissue. Theoret- 
 ically, it should yield better results than it does clinically, because the 
 longer cicatricial ti.'^sue is held on the stretch the less tendency it has to 
 recur and conversely the shorter the duration of the stretching the more 
 prompt the recurrence. Its percentage of cures, however, is suf^ciently 
 high to warrant giving it first trial. Deiavan has had a large experience 
 with, and excellent results from, intubation in chronic stenosis. ( Bib. 
 108, 109, 110, 111, 455.) Emil Mayer (Bib. 372) and A\'. Kelly Simp- 
 son (Bib. 49S) have had excellent results. All of these reports show 
 that great patience and prolonged treatment, usually a number of years, 
 are necessary for results. 
 
 Intubational dilatation should not be used in post-intubational post- 
 diphtheritic subglottic edema, because this form of stenosis yields more 
 readily to the author's method of galvano-cauterization (q. v. ) Intuba- 
 tional treatment is not satisfactory when tracheal stenosis coexists with 
 the laryngeal stenosis. Laryngostomy is preferable for such cases. 
 
 Intubation tubes and instruments. To be of any benefit in cicatri- 
 cial cases dilatation must be prolonged, and for this purpose nothing 
 equals the large size intubation tube modeled after the tube of O'Dwyer. 
 In cases in which the coughing out of the tube involves risk of closure 
 of the larynx with serious dyspnea, the subglottic retaining swell must be 
 large, and in most cases the author's personal preference is for a device 
 suggested to the author by a ]iatient with a luetic cicatricial stenosis. 
 It was a great comfort to this patient to know that the tube could not be 
 coughed out, and the author and Dr. I'atterson have subsequently used
 
 INTriiATKINAI. nil.ATATKIN OI- CIIKONIC I.AKVNCKAI, STENOSES. {i2-i 
 
 the same jilan in a minil)i-r of otliir cases with similar good results. It is 
 made of siher-plated brass, which is preferable to the hard rubber. The 
 post-tube also has the advantage of maintaining a large tracheal fistula 
 which is a great safeguar<l because the jiatient can learn to spread the 
 wound orifice himself if need be. 'The first ones were made of aluminum 
 because of the lightness. liut as aluminum is corroded by boiling and 
 
 F"-- 45.?- — KadiD^rapli (jf the living patient, .sliouing tlic author's self retain- 
 ing dilating intnhation tube in position in a man of eighteen .vcars, afflicted with 
 post-typhoiil lar.\ngeal stenosis. 
 
 even by secretions, we liaxc now abandoned it in fa\or of siKered Ijrass. 
 The author has tried the wearing of soft rubber tubes because of the ef- 
 fect of soft rubber in softening cicatricial tissue, but as the procedure 
 is not safe without tracheotomy, it is better to do a laryngostomy when 
 the effect of soft rubber is desired. < )tir screw-post tube was illustrated 
 (Fig. I.").'!) in the Laryngoscope, .September. 1!i()!i, without knowing that
 
 G24 INTUBATIONAL DILATATION OF CHRONIC LARYNGEAL STENOSES. 
 
 .Schmiegolow had used the principle in the tube, Fig. 434, in 1894 (Bib. 
 480, 481). John Rogers also developed a ver^- ingenious self retaining 
 tube and his methods and results are excellent (Bib. 455, 456, 457). 
 Priority in the self retaining principle, therefore, rests with Schmiegolow, 
 and the Rogers tube antedated that of the author. 
 
 For palpatory insertion of his tubes (Fig. 455) the author has 
 found the instrument shown in Fig. 45G to be preferable to the form 
 of instrument vLsed by O'Dwyer. Parenthetically, it should here be 
 stated that the author in referring to tubes and intubation instruments 
 refers only to such as are used in the dilatatory treatment of chronic 
 stenosis of the larynx. For dii)htheria and like conditions the author 
 has never seen any impro\ement on the original O'Dwyer apparatus. 
 For intubation and extubation by the direct method the author uses the 
 instrument shown in Fig. 457. 
 
 Fig. 454. — Self retaining intnhation tube of Sclimiegelow (Bib. 480, 481.) 
 
 I ntnhation and extubation. The method of ])alpatory introduction 
 is precisely the same as taught by O'Dwyer and fully described and il- 
 lustrated in the text books. In children palpatory introduction is quite 
 easy but in adults it is, in some cases, quite difficult until after much 
 practice. The larj'nx is usually so far down, especially when the patient 
 is retching, that the arytenoids cannot be reached by the finger, and in 
 many cases these landmarks have been destroyed by previous necrosis. 
 The right aryepiglcttic fold is generally present in some form and will 
 serve as a palpatory landmark. The direct method of intubation is 
 usually quite satisfactory though the supraglottic swell of the large adult 
 tubes will not go through any but an open laryngoscope. No special in- 
 strument is necessary for extubation. The post is unscrewed and re- 
 moved, and then the tube is pushed up into the pharynx with a hemostat, 
 being careful not to scratch the tube. The ])atient can usually eject the 
 tube from the pharynx, but, if not, the neck of the tul)e can be seized in 
 the pharynx with the operator's first and second fingers. 
 
 Care of patients under intnbational treatment for hiryn(/eal stenosis. 
 The tendencv of an intubation tube in the intnbational treatment is to
 
 INTI-RATIONAL DILATATION OF CHRONIC I.AKVNGICAL STP.NOSES. 625 
 
 sink lower and lower and also to bury itself below the epiglottis anterior- 
 ly. This must be combatted at first by the support afforded by the block 
 (C, Fig. 455) and later by keeping the tube up into its place with gauze 
 packing below the post in the cervical fistula. The post must be screwed 
 tightly with a hemostat to prevent its accidental unscrewing. The block 
 (C, Fig. 4.-)5) is usually dispensed with after the establishment of a long 
 well epidermatized trough. 
 
 It is quite essential that the tubes shall be of large size and that 
 they shall be worn constantly. The size should be increased up to the 
 
 Fig. 455.— The author's self retaining intubation tube for the treatment of 
 chronic laryngeal stenosis. The tube (A) is introduced through the mouth, then 
 the post (B) is screwed in through the tracheal wound. Then the block (C) is 
 slid into the wound, the square hole in the block guarding the post against all 
 possibility of unscrewing. If the threads of the post are properly fitted and tightly 
 screwed up with a hemostat, however, there is no chance of unscrewing and gauze 
 packing is used instead of the block to maintain a large fistula. The shape of the 
 intubation tube has been arrived at after long clinical study and trials, and cannot 
 be altered without risk of falling into errors that have been made and eliminated 
 in the development of this shape. 
 
 point where it requires a slight degree of force for insertion. Great care 
 must be taken, however, not to increase size too rapidly nor to carry it 
 too far. lest chondrial necrosis set in and make matters worse than be- 
 fore. T'sually once a month is often enough to substitute the next larger 
 size. The tube must be removed for cleansing every alternate day at 
 first. After a few weeks the duration may be increased until it can 
 remain in a week or even two weeks. Should swelling and tenderness 
 develop aroimd the wound the tube should be removed and cleansed. 
 Shdiild the inflammatory signs persist it may be necessary to substitute
 
 G2C, 
 
 INTUBATIONAL nil.. STATION' (11" CHRONIC I.AKVXGKAL STKNOSKS. 
 
 a trachcotomic cannula for a few days. Tlie position of the supraglot- 
 lic swell of the tube should bo watched daily jircfcrably by the laryngeal 
 mirror. Overhanging granulations, if any, should be removed with 
 tissue forceps, Fig. 35, by the direct method. Once every week, when 
 the tube is removed, a bronchoscope should be passed to note progress 
 and to remove deeper granulations, treat ulceration by applications, or 
 
 Fk;. 456.— Introducer for the author's self-retaining intubation tubes, when it 
 if desired to use the palpatory method of introduction. This instrument is for 
 adults. For children the O'Dwyer principle is preferable, if an indirect instru- 
 ment is desired. 
 
 Fui. 45;. — Introducer for placing the author's intubation tulies by tlie direct 
 method. For children the introducer of Mosher is better. 
 
 by change of tubal shape, or b\- temporary tubal discontinuance as may 
 be indicated. For this inspection the bronchoscope should always be 
 passed through the !ar\n.\; thus the approach is in what should be 
 the normal laryngeal and tracheal axes. In no case should the tracheal 
 fistula be allowed to close while the patient is under intubational dilata- 
 tion of a chronic laryngeal stenosis. Should an intubation tube become
 
 INTUBATIONAI. DII.AI'ATIOX Ol' ("ilUDMC I.AkVXCKAI. STI^NOSiCS. (327 
 
 i'ljstnK-t(.'(l suddenly a good traclical nurse can (.-xtubatc tlic patient liy 
 tlie method descriljed, and if needed for lirealhing, insert an ordinary 
 traclieotomic cannula temporarily. 
 
 I'rom time to time, after the first few months, the tuhe may he left 
 out for a few hours to note with the mirror and hy the breathing what 
 gain is being made in the area of cross section of the laryngeal lumen. 
 The duration of the extubation test period may be increased if the im- 
 ])rovement warrant, until finally the tube can be abandoned altogether. 
 The supreme test is the breathing at night. When this is quiet without 
 the tube the patient is a probationary cure, llis larynx must be watched 
 and. if need be. intubation resumed before his larynx gets too much 
 contracted. Six months without the tube may be called a cure. Fortun- 
 ately the fistula will usually stay patent during this time because it is 
 epithelialized with dermal eiiilhclinni, 1 1' it show an\- tendencv to close 
 comi)letely it must be kej)! open by the wearing of an obturator, which 
 consists in a silver iilug long enough barelv to reach the trachea, the plug 
 being metallicall, attached to a ta])e holder after the manner nf a tracheo- 
 tomic cannula. 
 
 'I'he treatnf.-iit may recpiire 'rcjni three months to fdur years. Dur- 
 ing this time the patient has a good whispered voice but cannot phonate. 
 He can attend to any work, even hard labor, provided his work dues not 
 re(|uire a voice; and provided he could, in cise of emergency, extubate 
 himself and |iul in a traclieotomic cannula. In miK' a few cases is the 
 secretion of such a nature as to bring about such ,in emergency after the 
 first three or four months of treatment. A few patients are afflicted with 
 a tubal accumulatior of a thick, gummy, adherent secretion which they 
 cannot cougii out of the tube. 
 
 The ultimate vocal results in the successful cases is excellent in ])ro- 
 jiortion as aryti-noid motility remains. In ankylotic and necrotic aryte- 
 noid conditions the |>;itient will get a loud thnugh rou.uli and intlexible 
 phonation. .Many patients ac<|uire a peculiar sidewise dip])ing of tlie 
 head, with working of tlie ])latysnia myoides and other cervical muscles 
 just as they commence to sjjeak. The ultimjite voice in ;idults is usually 
 lower in pilch than before treatment. In children time will work won- 
 ders in the de\elo;'ment of flexible, alnio-;t unimpaired voice.
 
 CHAPTER XL. 
 
 Laryngostomy. 
 
 Definition. L;)ryngostomy is the name given to the surgical pro- 
 cedure of laying onen the larynx anteriorly and keeping it open for a long 
 period of treatment. ]\Iore or less of the trachea is usually included in 
 the opening and the procedure is then laryngotracheostomy. 
 
 History. It was done for steno-is first by Heryng in 1894 (Bib. 
 215) and by Ruggi for recurrent papilloma in 1S!)8 (Bib. 461). It has 
 since been elaborated and developed by Sargnon (Bib. 472, 473, 474), 
 Canapel, Melzi, Cagnola, Barlatier, Baratoux, \'ignard and others. Sarg- 
 non's methods and results are especially worthy of study. 
 
 The author first performed it in ]!NiO, reporting five successful 
 cases, with exhibition of two of the patients at the meeting of tlie Ameri- 
 can Laryngologiral. Rhinological and Otological Society, February. 1904. 
 (Bib. 268). In these cases the author used the T-shaped silver cannula 
 shown at A and B, in Fig. 458, and a laryngostomy cannula (Fig. 
 459). In two of the cases the stenosis subsequently recurred. In 19(i6 
 Killian demonstrated a vastly better method by post-operative dilatation, 
 that made of laryngostomy an operation that has now a permanent place 
 in the surgery of the larynx. He also made use of a T-shaped cannula 
 (C, Fig. 458), but it was made of soft rubber and was used in successively 
 increasing sizes for dilatation. He had discovered that the contact and 
 elastic pressure of tiie soft rubber caused a softening and absorption of 
 the obstructive endolaryngeal tissue. Taking advantage of the ei?ect of 
 the contact of rubber tubing, the author fitted the rubber tubing in in- 
 creasing sizes .nnd of proper length for the particular case (Figs. 461 
 and 475) over the upnglit branch of his old laryngo'itomy cannula. (Fig. 
 459^. The results of this have been ideal. Sargnon suggested tying the 
 rubber drain to an ordinary cannula as shown in Fig. 462. Under his 
 skilful care this i)ro(luced excellent results, but in the hands of others
 
 LARYNCOSTOMV. 
 
 (32!) 
 
 great care has liecii necessary to combat its tendency to the development 
 instead of the ohhteration of the si>ur ( K, Fig. 4(iO), which all old can- 
 nula wearers have. Fournier suggested using an ordinary tracheotomic 
 cannula, the tubing ha\ing a side-opening through which the cannula 
 was placed. This also produced good results, but it does not obliterate 
 the spur (E, Fig. 460) like the author's apparatus. Fig. 4(J1. Mr. 
 Walter G. Howarth has had excellent results from dispensing altogether 
 with a cannula. (Fig. 4G4). The rubber tubing is cut long enough to 
 
 Fig. 458. — A. B., T-shaped separable tracheal cannula of the author. Each 
 section is inserted separately, then the two arc held together by the ring. (Bib. 
 268). The tape liolder retains the tube and dressings. C, T-sliaped soft rubber 
 tube of Killian. 
 
 Fk;. 459.— .Xuthor's laryngostomy cannula originally used without rubber tubing. 
 After Killian's discovery of the effect of rubber dilatation, rubber tuliing in increas- 
 ing sizes and of proper length has been placed over the upright branch tube, as 
 shown in the radiograph. Fig. 475, and the schema, Fig. 4O1. 
 
 extend down the tracliea past tli-: iistula and is held in place by ligatures 
 wiiich are fastenol to the middle of the tubing, opposite the fistula, by 
 passing the sutures through the wall of the tubing with a needle, before 
 the tubing is put m place. This method seems excellent, and is readily 
 placed without di.scomfort to the patient. Thosi does not use the soft 
 rubber softening and absorbing method. He inserts a smooth, hard-rub- 
 ber plug, or wedge, above the ordinary tracheal cannula as shown in 
 Fig. 4fi(!. Flis results are excellent. Much careful work, however, is
 
 G30 
 
 LARYNGOSTOMY. 
 
 _^ 
 
 Fig. 460. — Schematic representation of the problem involved in laryngeal 
 stenosis when the patient has been wearing a cannula for a long time. In addi- 
 tion to the original stenosis (L) in the larynx, the wearing of the cannula (C) 
 has built up the stenotic mass (E) in the trachea. S represents the skin and 
 T, TT, represent the trachea. 
 
 Fig. 461. — Schema showing the author's method of laryngostumy. The hollow 
 upward metallic branch (N) of the cannula (C) holds tlie rubber tube (R) back 
 firmly against the spur (^E) on the back wall of the trachea. Moreover, the air 
 passing up through the rubber tube (R), permits the patient to talk in a loud whis- 
 per, the external orifice of the cannula being occluded most of the time with the 
 cork (K). 
 
 Fig. 462. — Schema i-howing tlie method of Sargnon for after-treatment of 
 laryngostomy. Excellent results have followed this method. The tendency of the 
 cicatricial spur (E) to push forward the lower end of the rubber tube (R) should 
 be combated. The tubing, K, is plugged vvitli gauze at each dressing.
 
 LARi'NGOSTOMY. 
 
 031 
 
 needed to combat the spur, shown at E, Fig. 4()0. The patient has not 
 even a whispered voice while the pkig is in place, but doubtless this could 
 be remedied l)y an air canal in the plug. 
 
 Indications. \\ hen all else fails in a case of cicatricial stenosis, re- 
 course must ')e had to laryngostomy, and with ])ropcr patience in carry- 
 ing out the treatment, it will cure every case unless the loss of cartilage 
 is very e.xtensive. Formerly, in the stenosis due to chronically recurring 
 
 Fig. 46,v — Fournier's method of holding the rubber dilatatory drain in posi- 
 tion. B, rubber drain with side opening cut in lower end. A, tracheal cannula 
 attached to drain by passing the tube of the cannula through the side hole of the 
 rubber drain, where it is held by two ends of a suture to the staples of the tape 
 plate. The tubing is plugged with gauze at each drcsshig. 
 
 Fic. 464. — Method of Mr. Walter G. Howartli in laryngostumy. The cords 
 (H, H) transfixed through the wall of the rubber tubing (R). After tlie tube is 
 in place in the larynx and trachea the free ends of the cords are tied over the 
 large plug of gauze that is forced into the laryngostoiny opening in the effort to 
 keep this opening as large as possible. 
 
 |iapillumata in children, the author resorted U) laryngoslomy in iiuract- 
 ahle cases, but since perfecting the technic of direct removal, he has 
 found that by persistence with the extirpation and alcohol ai)|)lications. it 
 is possible ultimately to cure every case. There are a number of stenotic 
 conditions such as scleroma that doubtless would be benefited by laryn- 
 gostoniv, but the author has had no personal exjierience with tlu-m.
 
 632 
 
 LARYNGOSTOMY. 
 
 C OHtraindicatwns. Pyrexia is an absolute contraindication. Active 
 lues and active tuberculosis, local or elsewhere, do also. Bronchial and 
 pulmonary disorders greatly increase the risks and if irremediable, they 
 are contraindications. Serious organic disease anywhere is prohibitive. 
 Excessive loss of laryngeal and tracheal cartilage will preclude a success- 
 ful result. A purulent focus, as in the nasal accessory sinuses, increases 
 the risk but is not an absolute contraindication. 
 
 Ck 
 
 H^ 
 
 T 
 
 Fig. 465. — Special rubber tube of Moure for laryngostomy. The tubular parts 
 (L and T) are in the larynx and trachea, respectively, while the loops (M, M) 
 project through the external wound to keep it patulent. 
 
 Fig. 466.— Thost's apparatus for the dilatation of cicatricial laryngeal stenosis. 
 The hard rubber plug, B, is inserted from below upward before the ordinary 
 tracheal cannula, C, is inserted. 
 
 Instntmcnts. Besides general operating instruments, the reciuisites 
 are a blunt pointed bistoury, Moure's thyrotoniy shears or the turbino- 
 tome (Fig. 467), small retractors, silk for suturing the mucosa to the 
 skin. As in all external laryngeal surgery a small electric light, worn be- 
 tween the operator's eyes (not on top of the head) is essential. The 
 illuminating and the visual axes must almost coincide. For the post- 
 operative dilatatory dressings, soft rubber tubing evenly graduated in
 
 LARYNGOSTOMY. 
 
 0:5:3 
 
 sizes from ].") to 4.j French scale sizes is needed. These are unobtainable 
 in drainage tubinjj, but veterinary catheters answer admirably. These 
 tubes must be cut in length to suit the case, the cut edges being rounded 
 with sand paper or by singeing in the flame of an alcohol lamp, being 
 careful not to burn the ruViber, only to melt otT the sharp angle of the 
 cut edge. 
 
 Preliminurics. The patient's health, if improvable, must be im- 
 proved. Luetic cases should have at least one month's treatment, whether 
 active lesions are present or not. As in all operations about the air 
 passages, the mouth and teeth should be put in the best possible condi- 
 tion with the aid of the dentist if necessary. Alcohol "2.") per cent 
 strength is the best non-toxic antiseptic mouth wash. All proprietary 
 preparations are a delusion, unless they contain alcohol ; though they 
 
 Fig, 467. — Tiirliinotomc of the author, originally devised for turbinotomy but 
 found excellent for thyrotomy and laryngotomy. 
 
 may be used to flavor the wash. Diseased tonsils should be removed 
 radically and healing awaited. 
 
 Position of the patient. The patient is placed in the combined 
 Trendelenberg-Rose position to prevent aspiration of blood and secre- 
 tions. If the wound be not allovv-ed to close during the operation, the 
 retractors being always kept in place, the blood cannot be aspirated up 
 hill. If the edges of the wound be allowed to a])proximate there is no 
 longer an ojjcn trough, but a tube, continuous with the trachea, up which 
 fluids can be aspirated. 
 
 .■Anesthesia. Local infiltration anesthesia is far the best and safest 
 anesthetic. The solution we use is the same as for tracheotomy ( c|. v.). 
 The intradermatic. nftl hy])()dermatic, injection of this solution along the 
 line of incision, will produce absolute analgesia of the skin and partial 
 anesthesia of scar tissue. The interior of the larynx can be anesthetized 
 in adults by the local swabbing with a "iO per cent, cocaine solution. This 
 must be ai)plie(l throu!.'h the tracheal fistula before commencing to oper-
 
 (;34 
 
 LARYNGOSTOMV. 
 
 ate. It will have no effect afterward. The only really painful part is 
 the thyrotomic clip (Fig. 4()8) and this is over in an instant. 
 
 Operatioyi. For clearness the operation may be described in four 
 steps : 
 
 1 . Opening of the larynx. 
 
 2. Incision of the posterior wall. 
 
 3. Suture of the mucosa to the skin. 
 
 4. Placing of the dilating tube and the dressing. 
 
 ]. Laryngotomy. This step is described as dividing the tissues 
 layer by layer, skin, cellular tissue, fascia, thyroid gland, etc. Such pro- 
 cedure is a great waste of time. The simplest method, re(|uiring Init a 
 second or two, is to insert the lower blade of the inverted turbinotome 
 
 Fig. 468. — Turbinotumc 111 pu.-iition to make the thyrotomic clip. The table is 
 not shown steeply inclined toward the head as it should be before the turbinotome 
 is inserted. 
 
 (Fig. 4(>T ) in the tracheal fistubi, as shown in Fig. Kl.s. and to divide 
 all the tissues, including tlie skin, at one clip. The incision must always 
 extend to the tracheotomic fistula, no matter how low, in order that all 
 the conditions within to be dealt with may be exposed to view and treat- 
 ment. Thi.s applies with especial force to the granulatory or hyper- 
 plastic spur ( E, Fig. 4(!0), which is so often a factor in i)reventing de- 
 cannulation. In making this clif) in cases in which the thyroid cartilage 
 has been divided before, as is often the case in the cases that come to 
 the author, great care should be taken to follow the line of fibrous imion. 
 The thyroid cartilage rarely, if ever, unites with cartilaginous tissue, and 
 the island of cartilage (E, Fig. 4()9) produced by a cut in a new location, 
 is very likely to die. This is a disaster because it diminishes the already 
 deficient size of the larvngeal framework.
 
 I.ARYNC.HSTOMY. 
 
 G35 
 
 2. Incision of the posterior Tiv;'/ is hesl iloiu- with a sharp scalpel, 
 vertically, exactlv in the mctliaii line, clear ihrou^'h the scar tissue, hut 
 with great care not to incise the anterior esophageal wall. In intubated 
 cases the scars are usually on the posterior wall in the cricoid region, 
 and they should be di\ided through to the cartilage; remembering, of 
 course, that above the cricoid cartilage the posterior laryngeal wall is 
 soft, othervk-ise the esophagus might be penetrated. Xow we come to 
 the essential technical improvement of Killian. Instead of excising the 
 cicatricial tissue, and eviscerating the larynx, he took advantage of the 
 
 Fig. 469. — Scliema sliowiiig error to avoid in opening tlie larynx in any case 
 in vvliicli llie thyroid cartilage has been previously divided. If the new incision 
 (as at C, D) does not follow the line of tibrous union, A, B, the island of cartilage, 
 E, will likely become necrotic, still further narrowing the larynx and rendering 
 c'.ire extreinelv difficult. 
 
 Fig. 470. — Author's grasping forceps for external laryngeal operations. They 
 hold firmly large or small, protrud.ng or flat tissues, and do not tear out like all 
 forms (if toothed forceps do. 
 
 tendency oi the tissues to absorb and melt away under the contact and 
 elastic pressure of soft rubber tubing. The linear median incision is to 
 form a trench in wbii'li to lay the tube. Lateral cicatrices are not in- 
 cised, but left to disappear in the |'ost-(jperati\ e treatment. Sargnon and 
 1'arlatier ,'id\ise excision in cases of limited membranous cicatrices, plug- 
 ging the womid lor a few days with \aselineil g;mxe. In some cases 
 the author has fotind it advaiUageous to excise with curved scissors web- 
 like cicatrices, and also to excise \ery thick cicatricial inllltrations. thus 
 shortening the after treatment. I'nr gras]iing tissues within the larynx 
 the forceps, I-'ig. I7<i, are the best. 
 
 1. Placiiii/ (if the (lilatiiii/ tube, the cannula ami the dressiiij/. 'I'he 
 l)atient is now asked to cotigh, it. indeed, he has not been coughing freely.
 
 63G 
 
 I.ARYXCOSTOMY. 
 
 If the reader uses general anesthesia, he is urged never to have the 
 patient so deeply under that the tracheal cough retiex is completely abol- 
 ished. The laryngeal cough reflex may be more or less controlled as 
 desired by the preHminary use of cocaine. The tracheal cough reflex 
 
 Fig. 4/1. — Photograph of wound immediately after laryngostomy, before the 
 placing of the cannula, rubber dilating tulje, dilatatory drain, and dressings. The 
 silk-worm gut sutures uniting the skin to the lining of larynx have hemostats 
 attached to them. The suture ends were cut off afterw-ard. 
 
 Flu. 472.— RublK-r tube and cannula in place ready f.ir the application of the 
 dressings. 
 
 is the watch-dog of the lungs, as the author has so often urged, and 
 should never be abolished in the surgerj- of the air passages. The rub- 
 ber dilating drain is now cut to length. It should extend upward as high 
 as possible without interfering with epiglottic closure and downward
 
 I.ARYNGOSTOMY. 
 
 637 
 
 over all of the vertical liraneh <it the cannula. Its ui)i)er end is plugged 
 '.vitli gauze securely stitched to the rubber, lest it escape into the trachea. 
 The two ends of a braided silk cord, previously transfixed through the 
 wall of the lower end of the rubber tubing and tied, are now carried 
 outward and made fast, one end to the right and the other to the left 
 end of the tape holder of the tracheal cannula. They are drawn taut 
 in such a way that the soft rubber tubing cannot slide upward off the 
 vertical branch of the cannula. 
 
 "i. Siitui'c of the mucosa to the skin. The mucosa, or the cica- 
 tricial tissue of each lateral wall of the larynx, is sutured to the skin by 
 three or more deeply ])!aced silk-v.orm gut sutures which jiass through 
 
 Frc. 473. — .\ case of laryngostomy one month after operation. The epider- 
 matization of the laryngeal cavity is progressing. 
 
 the laryngeal lining and intervening tissues to and through the skin. 
 Superficial stitches slough out ni a few days. Care must be taken not 
 to lacerate the edges of the tracheal or laryngeal cartilages. Preserva- 
 tion of the cartilage is of jirimary imjiorlance in all stages. If there is 
 no cicatricial tissue at the divided edges to support sutures they had 
 better be dispensed with, because normal tracheal or laryngeal edges will 
 be lacerated. 
 
 Tn placing the apparatus it must he borne in mind that if the tube 
 were U> slide ujjward even slightly it would ride above the spur [E, 
 Fig. 4<>(i). 'I'he great efficiency of the autlior's method is due to its 
 keeping the soft rublH-r in perfect pressure contact with this spur, and 
 giving the straight nji and down line to the posterior tracheal wall as 
 shown in the radiogra])lis, Figs. 474 and 475. In placing the apparatus 
 the rubber tubing with braided silk conls atlaclied by suture to its lower
 
 638 
 
 LARYXr.OSTOMY. 
 
 Fig. 474. — Anteroposterior radiographic \ie\v of the author's laryngostomy ap- 
 paratus in situ, in a woman 27 years of age, affected with post-typhoidal cicatricial 
 laryngeal stenosis. 
 
 Fig. 475.— Lateral radiographic view of the same patient as shown in Fig. 474.
 
 LARYXCOSTOMY. 
 
 iVM 
 
 end, is inserted tliroiit;b the laryngostomy wound and pushed upward into 
 the larynx, the outer ends of the silk being prevented from escaping by 
 clamping a hemo-"tat on them. The special laryngostomy cannula is then 
 inserted into the tracheal trough. The rubber lubiug is then (lulled down 
 and made fast. 
 
 With this, or any other form of ajjparatus. if increa.-ed pressure at 
 one point is desirec'. the diameter of the dilating rubber tube may be 
 increased at the corresponiling point, as suggested by Sargnon and liar- 
 latier. by slipping over the tube another bit of tubing of the proper dia- 
 meter to be telescoped over, an^l of a length to correspond with the 
 
 Fig. 476. — .\utlior"s method of packing traclieal and external laryngeal vvnunds 
 tn keep tliem open. A double thickness of gauze is spread over the whole front 
 of the neck. The portion over the wound is then tucked into the wound. Then 
 a little hard roll of gauze is forced into the wound, carrying the double layer with 
 it. This form of dressing prevents any ends from getting down into the tracliea. 
 Useful in dressing lar\ngostomies, thyrotomies and tracheotomies. 
 
 vertical extent of the portion of the laryngeal or tracheal lunuii that 
 requires the additional pressure. 
 
 After the tube is placed the gauze dressing, in the form of a tight 
 roll of i)ro])er size, is smeared with sterile vaseline, and forced into the 
 wound in such a way as to keep it open. (Jnr preference is for the form 
 that we use in thyrotomy dressings. (Fig. ITfi.) 
 
 After-care. The dressing should be changed every three hours, the 
 gauze being wrung out of bichloride of mercury 1 :l(l,0(i(i solution. This 
 is contrarx' to routine surgery, but routine surgery has a high mortality 
 if applied to the larynx. Nurses trained in this laryngeal .uid tr.icbcal 
 work attend to the dressing imdcr the supervision of Dr. Mllen J. I'al-
 
 640 
 
 LARYNGOSTOMY. 
 
 terson, who dresses tlie wound once daily herself. In larvngostomies she 
 puts in place the increasing sizes of dilating tubes. If sloughing or too 
 great pain should supervene, it is well to omit increasing the size and let 
 the patient wear the same size or the next smaller size for a week or 
 more, as seems best. It is absolutely necessary to observe the utmost 
 vigilance to prevent any loss of what dilatation has been gained. A few 
 days without any dilating tube may seriously retard the cure. 
 
 After the first few days, the gauze plug stitched inside the upper end 
 of the rubber dilating tube is omitted and the patient can then speak in 
 a whisper, and can breathe through the mouth, the external orifice of the 
 cannula being corked. This is one of the great advantages of the author's 
 method. 
 
 The success of the operation, like all laryngeal surgery, is dependent 
 almost entirely upon the care, patience and skill with which this after- 
 
 FiG. 4-7. — Schema illustrating the author's method of hastening epidermatiza- 
 tion of a laryngostomy wound. An incision through the skin is made on each 
 side as shown by the dotted lines, C, and D. The skin is dissected loose from 
 the subcutaneous tissue (except at the edges of the laryngostomy opening) so as to 
 allow it to slide. If packing is put under to prevent it healing back into its old 
 position, it will be found in a few days that the skin has been drawn down into 
 the woimd as shown at E, F, thereby satisfying the tendency to contract. 
 
 treatment is carried out. The dilatation should be slow, making progress 
 no faster than the tissues will tolerate. Sloughing or excessive fetor 
 is a warning to ease up on the pressure. The sloughs and exudates are 
 usually infections of buccal origin. They are usually thin and may be 
 cleared away by mopping with hydrogen peroxid solution. They may 
 surround the stitches, which may have to be removed if the sphacelic 
 process is too severe. 
 
 The purpose is to get rid of the cicatricici! tissue ami to cover the 
 nezL'Iy formed lumen of the larynx first ziith small firm granulations, then 
 Zi'ith epidermal epithelium. This must be kept in mind in the after care 
 as it is the keynote to success. This epidermatization may take two 
 months or longer. It is claimed by some that some regeneration of 
 cartilage takes place. In many cases the wound seems to be shallower
 
 LARYNGOSTOMY. 
 
 (Ml 
 
 lhi>ii<;h larger. That i^, it is neaier tlie surface of the skin. A few re- 
 main deep. In tiiese deep cases we have found it advantageous to sHde 
 a section of skin on each side down into the wound as shown in Fig. 477. 
 Where the skin and subcutaneous tissue are not too cicatricial from re- 
 peated operation and the healing of open granulating wounds, this method 
 has also been verj' efficacious in preventing cicatricial contraction in 
 shallow cases. The method will be readily understood from Fig. 177 
 .\t .\ and at T. are seen the normal skin ed.;es dipping down into the 
 
 li'.. -17.S. — l-runi a ijliutograpli illustrating; llif iik'al rc-.-ult in hirxiigostomy. 
 \\'!u-n the niter-treatment has l)e:n properly carried cuit, tlie skin will lie pulled 
 dowr. into the wound in a funnel-like shape as here shown. It is an elongated 
 funnel, not a circular one. The actual skin surface should he drawn in, not 
 sinipl\' an epitlielialized cicatricial tissue. 
 
 tracheal wou)id. To obtain tlii'^ dip|>ing down of normal skin (not cica- 
 tricial tissue covered willi e]ii(Krnial epitlicliinin it is necessary to have 
 normal skin to bei^in with, and llie p'issibility of obtaining this will de- 
 pend somewhat upon the ])osition of the original tracheotomy. If the 
 laryngostomy has gone llirnugii perfcctlv normal skin and the after-pack- 
 ing has been carefully attended to, the skin surface should (lij) down 
 into the wound as shown at .\. I'.. l'"ig. 177, and in the phologra|)h. I"ig. 
 ■I7S. If, however, granulations h,a\e been allnwed to rise higher than the
 
 643 
 
 LARYXGOSTOMY. 
 
 edges of the skin the object will be defeated. But having obtained the 
 condition shown in Fig. 478, the author's method of preventing contrac- 
 tion has yielded excellent results. Not only does it satisfy the tendency 
 of the cicatricial tissue to contract but it also furnishes a good dennal 
 lining for the trachea, or, rather, for the new adventitious lumen that is 
 to supply the place of the old stenosed trachea. 
 
 Epidermatization is favored by the use of a ten per cent ointment of 
 scarlet red. 
 
 Fig. 479. — Schema of the autoplastic operation of Berger for closing a tracheo- 
 dermal fistula. A, elliptic incisions around the fistula. B, flaps turned epidermis 
 inward and sutured. C, manner of drawing together and suturing the skin to cover 
 
 the flaps. C.-Kfler Molinie). 
 
 Fig. 480. — Schema of the autoplastic operation of Gluck for the closure of a 
 tracheo-dermal fistula. A, form of incisions and flaps, one on each side of the 
 fistula. B, one flap turned back and sutured, epidermal surface inward. C, the 
 other flap dragged over to close the wound. (After Molinie.) 
 
 Duration of the treatment -".aries from three to six months, oc- 
 casionally longer. At the end of this time, it is in most cases possible to 
 close the laryngostomy by a plastic operation, but it is better not to do 
 so. No matter how promising the result appears, the small opening 
 should be allowed to remain patulous for a few months longer to facilitate 
 the watch for recurrence. In rare cases a number of years have been 
 required for complete cure. Xo case should be called cured until six 
 months have elapsed. 
 
 Aittof<lasty. The laryngostomy ojiening will rarely unite without 
 autoplasty because of its epidermatization. When autoplasty is required, 
 the Berger or Gluck operations, clearly shown in Figs. 479 and 480, 
 will usually close the opening perfectly, though a number of minor sec-
 
 I.AKYXGOSTOMY. 
 
 643 
 
 ondary operations are at times iiecessar)- to close little tistnlae which oc- 
 cur, usually at the corners of the flaps. Like all plastic operations, suc- 
 cess depends uj^on large well nourished flaps, placed without too much 
 tension. It is necessary, in males, to modify the shape of the flaps to 
 avoid if possihle the turning in of skin bearing coarse hair. The outer 
 surface of the skin Hap is always turned in toward the trachea. In one 
 
 Fk;. 481. — I'Voni a ]ilirU'igr,-L(il) oi a i>atioiit taken two \L-ars aflcT cniiipU'te 
 cure of obstinate cicatricial post-typhoid laryriRotraclical stenosis, by laryngostomy. 
 (Four years have elapsed since complete cure and plastic closure. Voice and 
 breathing arc excellent. I'alicnt was originally tracheotomizcd, in cxlmiiis. 
 by Dr. Joseph II. Barach). 
 
 of our cases, three plastic operations failed to close a fistula. The entire 
 front of the neck was a mass of scar-tissue. After each operation, a small 
 fistula would jiersist. We discovered that it was the ])ressure during 
 cough that forced a small (ijiening and forced the secretion out, thus 
 causing a leak. I!y doing a tracheotomy very low in the neck, the pres- 
 sure on the olastic above at the site of the laryngostomy during coughing 
 was completeh' i)revenled. .After healing of the laryngostomy opening
 
 644 
 
 LARYXGOSTOMY. 
 
 was complete, the cannula below was removed and the lower wound 
 packed in the usual way until it closed from the bottom up. This new 
 tracheal wound, not being epiderm.atized, healed in about ten days. This 
 patient, now four years after complete closure and six years after the 
 lumen was enlarged to the desired point, remains absolutely free of ste- 
 nosis and has now a good, though rough, voice. Figure 481 was made 
 from a photograph taken two years ago. In some instances we took the 
 tension off th.e plastic stitcher by the use of the lacing, Fig. 482. 
 
 Fig. 482. — Lacing adhesive strips for lessening the tension on the sutures ot 
 autoplastic flaps. 
 
 p 
 
 1 
 
 
 
 ^. 
 
 
 \, 
 
 i 
 
 « 
 
 1 
 
 
 t 'TM 
 
 Fk.. 4,S_i. — lUiisUauiig iIk- riMilt ui L^^^ll,l.;'.■^l"ln.* hi a boy o£ sixteen years. A, 
 post-typhoid laryngeal stenosis. The entire subglottic region is filled with inflam- 
 matory tissue, li.xing the cords. B, laryngostomy tube in situ. C, after four 
 months' treatment with the author's apparatus. D, two years after the tracheal 
 fistula was closed by autoplasty. (Laryngeal mirror views sketched from life by 
 the author.) 
 
 Results. Of the author's eighteen cases, two are still under treat- 
 ment. Two were cured by laryngostomy without dilatation, two recurred 
 and were afterward cured by the authors method, as described. The 
 other fourteen cases are well. The vocal results in all were very satis- 
 factory, and especially so in the cases with some degree of arytenoid 
 mobility at the start. Pitch was more or less altered, being in most in- 
 stances deeper.
 
 CHAPTER XLI. 
 
 Decannulation After Cure of Laryngeal Stenosis. 
 
 Abando)intciit of the cannula. When a tracheotomized case reaches 
 the stage, by whatever mode of treatment, when the patient is to be 
 trained to breathe aeain through the mouth, it is necessary to occlude 
 the cannula. The best method, in our experience, is to insert a rubber 
 cork in the inner cannula. It is quite unnecessary, with a properly fitting 
 cannula, to have a fenestrum in the tube. The fenestrum causes no end 
 of irritation and favors the formation of granulation tissue, because it is 
 impossible to have the fenestrum in tb.e lumen clear of contact with the 
 walls of the trachea. It is, anyway, unnecessary, because plenty of air 
 will pass the cannula if it be of the projicr size, and breathing can be 
 unimpeded without a fenestrum. If an attem]it is made to leave the 
 cannula out, no matter how well the i)atient may be able to breathe, 
 there is apt to be panic, because the removal of the tube is associated 
 with dyspnea in the earlier history of the case ; and associated ideas, 
 terror and nerve habit cause the panic. On the other hand, when a 
 cork is used for two or three weeks, the patient becomes accustomed to 
 breathing through the mouth and realizes that he can do so. When this 
 confidence is accjuired there will be no panic. In cases that cannot get 
 sufficient air through the mouth, a slot may be made in the cork for air 
 leakage as shown in Fig. 481. All decannulation cases must be closely 
 watched at night. .\ patient will Ijc quite dyspneic with a cork thai 
 can be comfortably worn in day time. In most instances where laryn- 
 gostomy has not been done the fistula into the trachea will close very 
 rapidly. 'I'his should be retarded all tliat is jiossible, and the wound 
 should be packed firmly open until the tracheal cartilage has united com- 
 I)letelv. Otherwi.se, there will be a mass of granulation tissue projecting 
 into the trachea at the site of the unhealed wotnid. In an acute case 
 where a tracheotoinv ha- been done for temi>orary .stenosis, if the wound
 
 640 DKCANNULATION AFTER CURE OF CHROXIC LARYNGEAL STENOSIS. 
 
 is allowed to heal promptly the cartilage will heal very, very slowly 
 and all the time v.ili be throwing granulations into the trachea, as the 
 author had abundant opportunity to observe with the bronchoscope some 
 years ago. (Bib. SiU)). These may become so large as to demand a sec- 
 ond tracheotomy. Of course, the granulations can be removed broncho- 
 scopically and resorcin or other applications thus made, but as a rule 
 it is better in such a case to open the tracheal wound again and deal with 
 
 Fig. 4S4. — Enlarged illustration of cork used to occlude the cannula in train- 
 ing patients to breathe through the mouth again, before decannulation. The groove 
 allows air leakage, the amount of which is regulated by the use of different corks 
 having various sizes of grooves as indicated by the dotted lines. A smaller and 
 still smaller air leak is permitted until finally an ungrooved cork is tolerated. 
 
 it properly by getting healing of the cartilage first. In cases in which the 
 cannula has been worn a great kngtlt of time the cartilage is, usually, 
 covered with fibrous tissue and possibly some extension of the tracheal 
 epithelium, but not enough to prevent a prompt union. It usually takes 
 but a short period of packing until the tracheal wound is united, and 
 the wound will begin to fill up from the bottom, when the packing will be 
 gradually, of necessity, less and less deep, until none can be inserted.
 
 CHAPTER XLII. 
 
 Malignant Disease of the Larynx. 
 
 A therapeutic cure for cancer remains to-day, as it always has been, 
 a hope long deferred. As applied to the larj'nx, there has, as yet, been 
 no result from the roentgen ray, radium, mesothorium, or other radio- 
 active substances, vaccines, diathermy, foetal autolytic products, or ionic 
 surgery, that renders their use advisable instead of operation in an oper- 
 able case ; but as post-operative measures to lessen recurrence and for 
 palliation, some of these measures seem to have value. Well planned, 
 careful, external operation followed by painstaking after-care, is the only 
 cure so far known and it is a cure only in a properly selected case. Endo- 
 laryngeal operation ( q. v.j is contraiiidicated except in minute growths 
 limitccl 1(1 the tip of the epiglottis, which are not strictly endolaryngeal. 
 
 I'ropliylactic treatment. Whether we regard the influence of irrita- 
 tion as a factor or not, and whether or not we regard the continuance of 
 chronic inflammatory processes as resulting in segregation of ephethelium 
 with subsequent proliferation as a factor in the etiology of cancer, there 
 can be no question in the mind of any one who will review all the evi- 
 dence, that there is, in many parts of the body, a certain precancerous 
 condition at the site of cancer. The author's case records afford 
 abundant evidence that it is exceedingly rare for cancer to develop in a 
 previously normal larynx. The history of almost every cancer case in- 
 dicates more or less annoyance referable to the larynx for so long a 
 period of time that we cannot ignore the influence of chronic laryngitis 
 as at least a oredisposing cause of cancer of the larynx. Specific ulcera- 
 tions and benign growths can prejiare a soil more favorable than normal 
 tissues for the invasion of cancer, and a rajiid cure of any form of cur- 
 able laryngeal disease is a i)ro])hylactic measure. 
 
 Palliative treatment. The four conditions that we must combat with 
 palliative treatment, are: (1) Odor. (2) I'ain. (:!) Dysphagia.
 
 C48 MALIGNANT nsKASi: OF THE LARYNX. 
 
 (4) Dyspnea. Odor is due largely to the saprophytes. To hold these 
 in check, the local use of antiseptics and, above all, the removal of secre- 
 tions before there is time for decomposition, are necessary. Hydrogen 
 peroxid to remove secretions, anrl dilute alcohol as an antiseptic, are 
 among the very best for these [uirposes. Pain may be, to some extent, 
 controlled by insufflation of orthoform and menthol. In dysphagia, in- 
 tubation of the esophagus will postpone gastrostomy until near the end. 
 When gastrostomy is indicated, however, it should be done at once and 
 not delayed until the patient has become moribund from starvation. For 
 odynphagia when due to ulceration of the epiglottis, the author's experi- 
 ence coincides with that of Sir St. Clair Thomson, in the relief afforded 
 by the amputation of the projecting portion of this structure. Amputa- 
 tion is a relatively minor procedure. For dyspnea, tracheotomy should 
 be done early before the patient's general condition sufifers. It should 
 always be done low in the neck, tlse it will soon be invaded by the can- 
 cerous process.
 
 CHAPTER XLIII. 
 
 Malignant Disease of the Larynx. — Continued. 
 
 CURATIVE OPERATIONS. 
 
 Contraindtcations to attempted cure by operation. The contraindi- 
 cations to an}- operation other than palhative are : metastatic foci, or- 
 ganic disease, feebleness, alcohoUsm, pyorrhea alveolaris, suppurative 
 disease of the accessory sinuses. A very high grade of malignancy is an 
 absohite contraindication to any operation other than palliative. This 
 seems to be the contraindication least often recognized. When the rela- 
 tively rapid increase of the growth in size, or the laboratory findings, 
 indicate a high degree of malignancy, or a very vulnerable soil (which is 
 probably the same thing) no operation whatever other than jialliative is 
 jjermissible, because recurrence is certain. Impossibility of entire re- 
 moval here, as elsewhere, is an absolute contraindication. Impossibility 
 of removal en masse of the cancerous tissue, involving the necessity of 
 incision through cancerous tissue or infected lymph channels, is an abso- 
 lute contraindication iflen ignored. It is useless to remove infected nodes 
 and leave behind the channels by which the infection was carried from 
 the original focus to the nodes. Not only will infection spread from 
 the unremoved channels, but the cutting through them will scatter the 
 infection which will be taken up by the open mouths of both lymph and 
 blood vessels. Careful esophagoscopy will often reveal infiltration of the 
 periesophageal glands, and when this condition is present, operation is 
 absolutely contraindicated, even if the glands are cervical. Within 
 the past year, the author has seen eighteen cases of malignant disease 
 of the JarjMi.x, in only one of which did he think operation advisable. Of 
 the seventeen cases in which he advised against any operation other than 
 jiaHiative. five cases were laryngectomized by otlier surgeons and all five 
 are now dead. The contraindications to oi)eration in e\ery one of these 
 cases was extension of the disease to the lower deep cervical and medias-
 
 G50 MALIGNANT DISEASE OF THE LARYNX, 
 
 tinal glands, and in four of the cases it was the bronchoscope and the 
 esophagoscope that served to point out the probability of deep medias- 
 tinal glandular involvements and disease of the party wall below the 
 larynx. One of the cases showed a very high degree of malignancy, 
 the growth quite evidently having extended from the larynx downward 
 and involving the trachea and parly wall in a period of about four or five 
 months. In such a case recurrence is certain, no matter how radical 
 the removal, and any operation is inadvisable ; but this patient found a 
 surgeon who would operate. The wound never completely healed, 
 malignancy being found in the granulations and rapid extensions soon 
 terminated the case. Any operation other than palliative is absolutely 
 contraindicated when there is involvement of the party wall below the 
 second ring of the trachea. This is not because the second ring of the 
 trachea cannot be removed, but simply because the bronchoscope and 
 esophagoscope in our clinic have shown that when any malignant growth 
 has gone below the second ring of the trachea, there is involvement of 
 the mediastinal lymphatics. There is only one way in which to select 
 the cases suitable for operation, and that seems exceedingly difficult to 
 do, for most men. If every one were to approach every problem of 
 operability with these two things in mind; namely, (a) mortality, (b) 
 recurrence, the general average of the published statistics would be 
 vastly better. The tendency is to go on the principle of "We will give 
 him a chance, anyway." 
 
 Choice of operution. In an early intrinsic malignancy of very 
 limited extent, not involving the posterior portion of the larynx, the re- 
 sults of thyrotomy Iiave been positively brilliant. Nowhere in the whole 
 realm of the surgery of malignant diseases have such results been ob- 
 tained as in thyrotomy in such cases. But unfortunately, thyrotomy 
 is being done on cases in which it is doubtful if even laryngectomy could 
 save the patient's life. Cases have come under our observation where 
 we advised against thyrotomy, but the patients afterward were thyrot- 
 omized by other surgeons, and in every single instance the disease re- 
 curred. In two of the cases, laryngectomy was afterwards done, follow- 
 ed by a second recurrence and fatal termination, one case within twelve 
 months, and the other fourteen months from the time of the original 
 thyrotomy. The author hopes that he will not be considered egotistical 
 in making these statements. He claims no originality whatever in the 
 matter; simply having followed the initiative of Sir Felix Semon and 
 Sir Henry Butlin, wlio, seconded by Sir St. Clair Thomson, Mr. Tilley. 
 Dundas Grant, Richard Lake, Prof. Moure and others, have very clearly 
 defined the limits of operability and have conclusively proven that it is
 
 MALIGNANT DISEASE OF THE LARYNX. C>')\ 
 
 only in intrinsic malignancy of very limited extent that good results can 
 be expected of thyrot(jmy. Notwithstanding this, thyrotomies are to-day 
 being done upon patients in whom there is very extensive disease, which 
 has gone beyond the limits not only of the intrinsic area, but of the en- 
 tire larynx. If operators wisii to operate upon such cases, they at least 
 should not report them as thyrotomies and befog the issue and mar 
 statistics by operations upon unsuitable cases. The author hopes that he 
 will be pardoned for speaking thus plainly aliout these matters, but he 
 feels very strongly upon the subject, for the reason that his own work 
 has convinced him of the beautiful results obtainable by thyrotomy in a 
 properly selected case. 
 
 It is frequently stated that the larynx is poorly supplied with lym- 
 phatics, and this is given as the reason for the good results obtainable by 
 thyrotomy in properly selected cases. This is an error. The larynx is 
 very abundantly supplied with lymphatics and they anastomose with each 
 other very freely, but instead of leading out by many channels they 
 empty into two small glands on each side without any anastomosis with 
 neighbiiriiig lymphatic systems (Cuneo). To this peculiar lymphatic ar- 
 rangement is due the success of thyrotomv in the hands of the few 
 operators who have limited its use strictly to a properly selected case and 
 who ha\e had the most brilliant results in the surgical treatment of 
 malignancy in any part of the body. The statement sometimes made 
 that cancer will not invade hyaline cartilage and that this is the reason 
 for favorable results in early and radical laryngeal operations, is an error. 
 Malignant epithelial proliferation will not primarily invade cartilage; 
 but when cancerous processes proceed to ulceration with consequent sec- 
 ondary mixed [lyogenic infections, the cancerous processes will follow 
 the suii]iurati\e processes through the damaged cartilage. Thus we not 
 infreipicntly see cancer, in its later stages, perforate the thyroid cartilage. 
 I'he real reason for the success of early operation in laryngeal malig- 
 nancy is that, liecar.se of the peculiar lymphatic arrangement mentioned 
 above, the anteriorly located, intrinsic cancerous process does not, for a 
 long time after its incijiiency. reach the cartilage. .Another phase of the 
 subject, lost sight of by those wlio state that hyaline cartilage is not in- 
 vaded by cancer, is that sarcoma is a form of malignancy that occurs in 
 the larynx and it may invade the cartilage early. In one case seen by 
 the author the origin was in the perichondrium and the cartilage was 
 probably involved almost from the incipiency. In another case a laryn- 
 geal endothelioma had its origin apparently from the perichondrium, 
 with early cartilaginous involvement. 
 
 Indicationx for tliyratoiny. Thyrotomy is indicated in any instance 
 in which the involvement is intrinsic and is so slight that there is a
 
 652 MALIGNANT DISEASE OF THE LARYNX. 
 
 practical certainty that all of the growth may be removed by cutting 
 through normal tissue and not through neoplastic tissue. In other words, 
 the cancer must not only be intrinsic, but it must be of very limited ex- 
 tent. If it be quite extensi\e, even though still intrinsic, it is reason- 
 ably certain that at thyrotomy all of the tissue cannot be removed. 
 Fixation of the cricoarytenoid joint renders party wall invasion probable 
 and if long continued a recurrence will probably follow operation. 
 
 Indications for laryngectomy. Laryngectomy is indicated in any 
 operable case of intrinsic cancer of too great an extent to be dealt with 
 by thyrotomy without cutting into neoplastic tissue. Laryngectomy is 
 indicated in laryngeal cancer extrinsic by origin or extension, if there is 
 little or no adenopathy, provided there are no contraindications (q. v.). 
 
 H cmilaryngcctomy. As stated some years ago, the author rarely 
 advises the operation of hemilaryngectomy, because of the much greater 
 infective risk as compared with total laryngectomy. In such cases as 
 are deemed operable, and in which the disease cannot be completely re- 
 moved by thyrotomy, it has seemed better to do a total operation, which 
 is safer because the trachea is entirely cut off and brought forward 
 through the skin, so that infection cannot set up septic bronchitis. 
 
 Hemicricoarytenoidcctomy has. in our hands, been followed by recur- 
 rence requiring the total operation. 
 
 Subhyoid pharynyotomy was formerly a very useful method of gain- 
 ing access to the upper orifice of the larynx. It has been entirely sup- 
 l)lanted for all benign conditions by direct endoscopic methods. For 
 malignancy it seems rarely justifiable because of prompt recurrence after 
 remo\al in this region. 
 
 MORTALITY AM) RESULTS OF OPERATION. 
 
 Three things have, in the past, rendered records worthless and have 
 very much befogged the statistics of the mortality and of the end-results 
 of radical operation for cancer of the larynx. 
 
 L The operation of thyrotomy has been confused with the opera- 
 tion of laryngectomy. 
 
 2. Nearly all of the cases operated upon for thyrotomy were not 
 suitable cases for this operation. In fact very few were operable at all 
 by any method. 
 
 3. The difficulty not on\\ in discovering the disease early, but of 
 getting the opportunity to o[)erate early. Both of these difficulties are 
 less than in the author's early days. Then patients did not so frequently 
 consult the laryngologist for seemingly minor ailments ; then, also, when 
 malignancy was discovered early, the patient started on a search for
 
 MAI.ICN'AXT rUSKASE OF TIIK I.ARYXX. G53 
 
 some one who would tell him he had no cancer. Such were almost al- 
 ways found in those days and the patient's only opportunity for cure 
 was lost by delay. 
 
 One thing stands out clearl_\- in the results of to-day as compared to 
 those of many years ago: namely, the relatively slight operative mortality 
 of total laryngectomy. When the author took up the surgical treatment 
 of laryngeal malignancy, laryngectomy was still under the blight of the 
 pre-aseptic days. Even after the general establishment of surgical asepsis 
 in practically all other fields of general surgerj-, aseptic technic, especially 
 in the dressings, was neglected because of the impossibility of absolute 
 sterilization of the field and prevention of its subsequent contamination. 
 To-day the average operative mortality in the large clinics is about ten 
 per cent and this can be greatly reduced by refusal to operate except upon 
 the most favorable cases. Though largely freed of its operative risk. 
 lar_\ngectomy cannot be said to be frec|uently curative of cancer, and is 
 rareh- advisable. As pointed out by Delaxan (liib. IKi and llS) the 
 exact curative value of total larvngectomy has not yet been determined 
 statistically because the literature is entirely made up of glittering gen- 
 eralities, incomplete statistics and cases reported too soon after opera- 
 tion. 
 
 Causes of death, in laryiu/ectoiiiy. The operation of laryngectomy 
 is necessarily associated- with a certain degree of shock. Therefore, or- 
 ganic disease or lowered vitality of the patient, necessarily assumes first 
 ])osition as a factor in mortality. Injury to parathyroids has undoubt- 
 edly been a factor in some instances, and injiu-}' to both vagi doubtless 
 has occurred. Infection of one vagus leading to an acute infective 
 vagitis, may jiroduce marked symptoms of depression, and may even 
 prove fatal. Sloughing of the esophagus and other infective conditioiis, 
 together with all forms of sepsis, and especially septic mediastinitis liave 
 been reported by a number of operators as causes of death in laryngec- 
 tomy. 
 
 Excessive traction upon the esophagus, as demonstrated by sphyg- 
 momanomelric tracings (l'"ig. 485) made upon some of the author's cases 
 by Dr. Iloyce (Tiib. 254) introduces a serious factor through cardiac 
 inhiliition as will be understood from the following notes of Dr. Boyce : 
 
 ■'In regard to your last thyrotomy (for epithelioma of the larynx) 
 in which I took sphyi?:momanonietric readings, they never fell below what 
 I take to be the patient's ordinary tension, lie was at no time deeply 
 anesthetized, and frequently struggled. The high readings 1 attribute 
 rather to muscular etfort than to operative irritation. In regard to the 
 two laryngectomies of \ours in o.hich I took siihygmomanometric read-
 
 634 
 
 MALIGNANT DISEASE OF THE LARYNX. 
 
 ings, I may say that the most interesting feature of the blood-pressure 
 chart in the case of Mr. P. was the fall that occurred when the larynx 
 was turned upward. A subsequent fall occurred when the upper 
 end of the esophagus was drawn on just previous to incising it. In the 
 subsequent case of laryngectomy, that of Mr. ^L, the blood pressure was 
 seen to fall steadily as long as the esophagus was being manipulated. In 
 this latter case the fall went almost to the danger point I had fi.xed on 
 in my mind as the one at which the operation should be stopped. This 
 fall of pressure is so remarkable, and so out of proportion to the appar- 
 ent severity of the operation, that it suggests the theory that the de- 
 
 Chan af jphygiiomanomftrif RMrfirgf; * -ing La^rgectOTiy f'*' 
 
 Fig. 485.— Chart of sphymomanometric readings recorded by Dr. John W 
 Boycc dnring laryngectomy by the author. 
 
 pressor nerve mechanism of the human heart runs in the substance of the 
 esophagus. If so, it might account not only for death on the table, said 
 to occur in these operations, but also, by the profound prostration in- 
 duced, for some of the inhalation pneumonias that are reported as fol- 
 lowing. Whether other observation shall confirm this theory or not. 
 the practical efYect indicates most extreme caution in making traction 
 on the esophagus, and that incisions into it should be made with the part 
 as nearly as possible in its natural position." 
 
 The author has had only two deaths from any cause whatever with- 
 in a month after the operation of laryngectomy. One of these was 
 due to sloughing of the esophagus, and the other to exhaustion produced 
 by a severe therapeutic test, in which enormous doses of potassium iodid
 
 MALIGNANT DISEASI- OI- TIIR LARYNX. ()■'>') 
 
 and mcrcun- had %ured. Since this instance, it has been the author's 
 practice invariably to insist upon full recuperation after all therapeutic 
 tests, before undertaking operation. 
 
 Recurrence. The deficiency of the lymphatic drainage from tlie 
 laryn.K renders extension exceedingly slow, so that laryngeal cancer is, 
 in its early stages, a purely local process, and as such is curable by 
 sufficiently wide removal. Recurrence within a year after operation may 
 mean that the operat;ve removal was inadequate, but it seems quite cer- 
 tain that in some instances, at least, it may be due to infection at the 
 time of operation owing to cutting through malignant tissue, as evi- 
 denced by a point of recurrence in the midst of cicatricial tissue. Recur- 
 rences either at the original site, or in remote locations after a period of a 
 year, may be looked upon as reinfections on a vulnerable soil. In one 
 previously reported case of the author, a patient died of cancer of the 
 stomach seven years after larj'ngectomic removal of a cancer from the 
 larynx. This well known case is everywhere regarded as reinfection 
 upon a vulnerable soil rather than repuUation of the primary process. 
 Had it recurred in the neck in the region from which the larynx had 
 been removed, it would have been regarded as a recurrence. (See com- 
 ment of Sir Felix Semon, T'.ib. -!!>4.) It seems that, for the practical 
 determination of the adequacy of an operation, we may sa)- that freedom 
 from recurrence for a period of one year after operation indicates ade- 
 quate removal though not necessarily a cure. Everything in the clinical 
 history of cancer indicates that it requires a vulnerable soil. We cannot 
 cure vulnerability of soil by operation nor by any other known means. 
 
 For statistics and valuable data proving the remarkable curative ef- 
 ficiency of thyrotomy the reader is referred to the liibliography for ref- 
 erences to various articles by Sir Felix Semon, to whom the world is 
 indeltted for the discovery of a cure for that dreadful aflliction, malig- 
 nant disease of the larynx. Convincing data will also be found in tlie 
 writings of Sir Henry i'.utlin (llib. i '>■'<) . Sir St. Clair TlKinison (I'.ib. 
 53S), Mr. Tilley, Dundas C.rant, Richard Lake, Mr. ikirwell. .Xdam 
 Brown Kelly, Logan Turner. E. j. Moure, Watson Williams. Dan .\lc- 
 Kenzie, Sir W. Milligan, William Hill, Stuart-I.ow, jobscm llorne. Hun- 
 ter Tod. Douglas Harmer and others. 
 
 Statistics. In publishing, herewith, statistics of every case he has 
 ever radically operated ujion, the author acknowledges that he has al- 
 ways refused to operate on any but the most hopeful cases, and the re- 
 sults are not claimed to be due to any superiority of organization or of 
 technic, but just simj'ly to llie firm resolution to say "No" in any but 
 the most hopeful cases. This has been done with the object of determin- 
 ing what may be accomplished by the operation of thyrotomy when
 
 656 MALIGNANT DISKASi; OF THE LARYNX. 
 
 Strictly limited to properly selected cases. Of the 211 cases of malignancy 
 in the larynx, four were sarcomata, one was an endothelioma, and the 
 balance were all carcinomata. In eight instances, the malignancy was 
 concurrent with lues, in three with tuberculosis ; and in two instances 
 tuberculosis, lues and carcinoma all were present in the form of a mixed 
 lesion ( iiili. 2.");!). Since thyrotomy is such an ideal operation for in- 
 trinsic malignancy, it may be wondered why out of 118 apparently in- 
 trinsic cases only "^V were thyrotomized. The cases not th^rotomized 
 were in five classes. 1. Cases seen in consultation with other operators 
 who themselves did the operation. '2. Cases in which the patient re- 
 fused operation. 3. Cases in which, though the growth still remained 
 intrinsic, it was of too great an extent. 4. Cases in which organic dis- 
 ease elsewhere contraindicated operation. '>. Cases in which at thyro- 
 tomy the disease was found to have gone down the party wall, or else- 
 where invaded the tissues of the neck to such an extent that a more 
 radical operation than thyrotomy was indicated. In our later cases, 
 such discoveries at thyrotomy have not been made because bronchoscopy, 
 esophagoscopy and direct laryngoscopy have enabled us to exclude in- 
 volvements lower down, such as subglottic infiltrations, and particularly 
 involvement of the party wall not visible by ordinary indirect examina- 
 tion. In May, 1909, in a paper read, by invitation before the Xew York 
 Academy of IMedicine (Bib. 250), the author reported the statistics of 
 all the malignant laryngeal cases in his clinic to that date. The cases 
 seen since are incorporated with that report in the following complete 
 record of all cases seen by the author: 
 
 Of ] I laryngectomies, two died within thirty days, giving a 14 per 
 cent operative mortality. Four died within a year of local recurrence, 
 three lived one year and were thereafter lost to observation, two lived 
 two years, dying of recurrence, one two and one-half years, dying of 
 recurrence, one three years, dying of cerebral hemorrhage, one seven 
 years, dying of cancer of the stomach. Recapitulating this, of fifteen 
 complete laryngectomies, eight of the patients were free from recurrence 
 at the end of one year, yet all arc dead now, and the average duration 
 of life is but little over one year. These statistics were based on a com- 
 plete report of all the author's cases five years ago. and he has not since 
 done a total lar> ngectomy. Hy this it is not meant that such operations 
 are decn.ied altogether unjustifiable, but cases where he felt that he could 
 honestly advise laryngectomy have not since come under the author's 
 care for operations, though he lias seen two operable cases in consulta- 
 tion that were very successfully done by another operator, both being 
 alive now at the end of one year and of fourteen months, respectively. 
 Tabular reports of all cases in the author's clinic follow.
 
 MALIGNANT DISKASK OI" IIIF. LARYNX. 657 
 
 TABLE I. 
 
 CANCER OF THE LaRYNX. 
 
 Cases of malignant disease of the larynx seen in 27 years, 1886 to 1913 211 
 
 Of these the disease was apparently intrinsic in I18 
 
 The disease was extrinsic by origin or extension in 93 
 
 Of the extrinsic cases the growth had extended beyond the limits of the larynx 
 
 m .,. 36 
 
 Number of patients operated upon (94 operations) 88 
 
 These operations were : 
 
 Palliative tracheotomies, esophageal intubations, etc 36 
 
 Thyrotomies 27 
 
 Complete laryngectomies 14 
 
 Subhyoid pharyngotomies - 9 
 
 Hemicricoarytenoidectomies 2 
 
 Partial laryngectomies included under laryngectomies (done later) 3 
 
 Partial laryngectomies included under thyrotomies 3 
 
 Of the laryngectomies and pharyngotomies there were extirpations of the 
 
 cervical esophagus in 6 
 
 Of the laryngectomies and pharyngotomies there were extirpations of other 
 portions of neck, includmg the external, internal and common carotid 
 arteries, pneumogastric nerve, jugular vein, sulimaxillary gland, lymph 
 nodes, tongue, hypo-pharynx, etc 8 
 
 TABLE n. 
 
 Thyrotomy. 
 
 Number of operations -7 
 
 Alive and well after thirteen years i 
 
 Alive and well after ten years i 
 
 Alive and well after eight years I 
 
 Alive an<l well after seven years 3 
 
 Alive and well after six years 3 
 
 Alive and well after five years 4 
 
 Alive and well after four years - 
 
 Alive and well after three years 2 
 
 Alive and well after one year i 
 
 Died of general diseases after one year 2 
 
 Lost trace of after one year 4 
 
 Died of recurrence (in spite of sul)sequent laryngectomy) 3 
 
 Died within thirty days o 
 
 Recapitulation: Of twenty-seven thyrotomies, twenty-four of the patients were 
 free from recurrence at the end of one year. No operative mortality. 
 
 It will be noted in the table that the extensive operations upon the 
 neck and esophagus and tissues adjactnl to the larynx are just the same 
 in number in the statistics published in 1'.)o!». They are included here 
 simply for completeness. The reason that none of these operations has 
 been done in our clinic in the past live years is that in none of the 
 cases that \vc have .ccn did conditions seem to justify such extensive
 
 658 
 
 MALIGNANT DISEASE OF THE LARYNX. 
 
 operation, for the reason that in p/ractically all of them that might have 
 been so operated, \vc have discovered, endoscopically, deep cervical or 
 mediastinal lymphatic extension which rendered operation unjustifiable. 
 Vocal results after operation for malignant disease of the larynx. 
 In all of our cases of thyrotomy, the patients have been able to phonate. 
 The voice has been really a good voice for all practical purposes. In 
 twentv of the cases, the voice had a considerable degree of flexibility. 
 
 Fig. 480. — From a photograph of a man of fifty-four years, taken six months 
 after laryngectomy for cancer of the larynx. About 5 cm. (vertically) of the in- 
 volved anterior esophageal wall was removed, the edges being stitched to the skin. 
 The upper aperture seen opens into the esophagus; by drawing it together with 
 the fingers swallowing was easily accomplished. The lower opening is the orifice 
 of the amputated trachea which was stitched to the skin. By placing a rubber 
 colostomy pad over both openings the tracheal expiratorj- blast went through the 
 mouth, giving the patient a Inud whispered voice. 
 
 In two, the voice was very rough and lacking in flexibility, though quite 
 loud. In four other cases, it was necessary to damage the arytenoid 
 joint in order to make sure of getting enough peri-neoplastic normal 
 tissue. The voice, though useful, was not loud in any of these but was 
 more of the nature of what is commonly known as a "stage whisper." 
 In two of these cases, removal of one arytenoid was required to get the 
 necessan' width of normal. In both cases there was no attempt to form
 
 MAI.ICXAXT I:ISI-;aPK 01' TlIK I.ARYW. 
 
 659 
 
 an adventitious \c)cal cord, corroborating^ the author's previously pub- 
 lished original observation that the traction by the arytenoid is the chief 
 factor in the formati-in of adventitious vocal bands. In two cases the 
 ventricular bands phonated excellently, there being no tendency to the 
 generation of adventitious bands after removal of both arytenoids. In 
 another instance both ventricular bands and the normal and the 
 adventitious bands, all four vibrated on jihonation. In the laryngec- 
 tomic cases, one failed to develop a buccal voice, because he would 
 
 N 
 
 KiG. 487. — From a iiliotojjrapli of a man of 68 years, taken nine montli.s after 
 laryngectDmy for endotliclioma of the larynx. The trachea was stitched to the 
 skin an<l the pharyn.x closed. (Author's case. For interior view of pharynx sec 
 Fig. g. I Mate II.) 
 
 not try with sulTicii nt patience and jiersistence. in one, a very 
 good useful voice resulted from the use of a colostomy pad, which 
 connected the two oi)enings, tiie jiharNngeal and the tracheal, externally 
 on the skin surface ( I"ig. ISii) as pre\iouslv reported (Bib. 354). 
 
 I'ndoubtedly llie stitching of the trachea to the skin, as first done 
 i)y Solis Cohen, decreases the mortalitv of laryngectomy ; but on the 
 other hand, as pointed out by Sir St. Clair Thomson, the patient's con- 
 dition, should he survive, is very much better and more enjoyable if
 
 660 MALIGNANT DISEASE OF THE LARYNX 
 
 the Upper and lower air passages can be connected. In Sir St. Clair 
 Tliumson's case, the patient used an artificial larynx for breathing and 
 speaking, and needed to remove the cork only when unusual exertion 
 called for extraordinary respiration. In one of our cases a secondary 
 operation to open the pharyn.x above the tracheo-dermal opening was 
 very successful as to breathing and voice with a prothetic apparatus, but 
 buccal and pharyngeal secretions caused considerable annoyance. 
 
 Summing up the \ ocal results after external operation for malignant 
 disea.se of the larynx, it is well to keep in mind, as mentioned in 
 connection with endolaryngeal evisceration, the vocal results depend upon 
 the degree of arytenoid mobility present after operation, because, as 
 previously demonstrated by the author, it is the tugging of the aryte- 
 noid that is the chief factor in the development of an adventitious cord. 
 \\'hile the ventricular bands may, and often do, assume the function 
 of the lost cords, yet their phonatory result is nothing like as good as an 
 ad\'entitious cord with good arytenoid mobility. Moreover, the ventricular 
 band of one side may require extirpation in the wide removal necessary 
 for the cure of malignancy, for under no circumstances should any of 
 the foregoing considerations of vocal results lead the operator into the 
 error of insufficiently wide removal. It is well also to remember that 
 at best the buccal voice and the artificial larynx are incomparable to even 
 a whispered laryngeal voice, therefore, laryngectomy is warranted only 
 when nothing less will offer good hope of cure. But, finally, no con- 
 sideration of conservation of voice should weigh against life-saving 
 thoroughness of extirpation.
 
 CHAPTER XLIV. 
 
 Technic of Thyrotomy for Malignant 
 Disease of the Larynx. 
 
 Preparation of tin- palicnt. <_)rai sepsis is the greatest elenient of 
 risk in any laryngeal operation, therefore the most important part of the 
 preparation of the jiatient is to have carious teeth filled or removed and 
 to have the entire mcjuih put in as clean and as healthy a condition as 
 possihle by the dentist, and there must be no hesitation in removing ques- 
 tionable teeth. Frcf|uent brushings of the teeth with a good paste or 
 powder of which chalk is the base, together with frequent rinsings with 
 alcohol 2.") per cent, which is the best non-toxic antiseptic, should be kept 
 up before as well as after operation. The usual general surgical prepara- 
 tions should be carried out in every detail as to bath, laxative, fast, etc. 
 The beard and moustache should be renimcd. if the patient have these, 
 and the face should be freshlv shaven the morning of the day of opera- 
 tion. 
 
 .Incsthcsia. When the autiior had developed a local anesthetic 
 technic to the |ioint where thyrt)tomy in any man of normal courage 
 could be done under hn-al anesthesia, he felt that a very distinct advance 
 had been made in his work, but since operating upon the last few ca.ses 
 under intratracheal insufllation anesthesia with ether, using the Elsberg 
 apparatus, there seem to be Wxc great advantages in favor of ether, 
 when used by insul'llution. In the first place, the return flow of air and 
 ether \apor remove from the trachea, and keep out of the lower air 
 passages, all blood and secretions. ( ■.' ) The cough reflex can be abolish- 
 ed for a few moments at a time, \\henc\er desired, and as promptly 
 brought back b\- switching fr(]m ether to jjure air. ( :"! ) When the insul- 
 flation tube is inserted, there is no more concern about the anesthetic, save 
 to ask the anesthetist to increase or lessen the depth of anesthesia, as 
 desired. (4) The great saving of ojierative duration o\ er lracheotom\
 
 663 TKCHNIC OF THVROTO.MV FOR MALIGNANT DISEASE OF THE LARYNX. 
 
 which formerly was used by some operators for the dual purpose 
 of administering the anesthetic and of tamponning the trachea with a 
 tampon cannula, (."i ) The anesthetist is removed far from the operator's 
 way. Should it later be found necessary to abandon the thyrotomy 
 and do a lar\-ngectomy, all that is necessary is to incise the trachea 
 below the involvement and insert a fresh sterile insufflation catheter 
 through the incision, the insuftlation nozzle being transferred to the 
 new catheter. In doing the (iluck operation of laryngectomy from 
 above downward, the catheter can be inserted into the upper orifice of the 
 larynx through the upper part of the skin incision, and the peroral tube 
 removed. In either case the result is the same. The anesthetizing tube 
 is entirely out of the operator's way, and combined with the Trendellen- 
 berg position, the flow of blood is entirely upward. It cannot reach the 
 lower air passages because of the return flow of air. It is surprising 
 how little space the insufflation catheter occupies in the larynx. One 
 would have anticipated that it would be considerably in the way in the 
 operation of thyrotomy, but on the contrary it remains closely in the 
 posterior portion of the larynx (Fig. 488) and could easily be moved a 
 little to one side, if it were necessary to excise any piart of the posterior 
 wall. As a matter ot fact, if it is necessary to excise any part of this 
 wall, the operation of thyrotomy is contraindicated anyway, for rea- 
 sons already mentioned. Another great advantage of insufflation anes- 
 thesia in thyrotomy is that the operative incision need be only long enough 
 to expose the thyroid and cricoid cartilages, consequently, the isthmus of 
 the thyroid gland need not be divided, thus saving much time in ar- 
 resting oozing, etc., as compared to the long incision required for the in- 
 sertion of a tracheotomy tube for anesthesia below the thyrotomic wound. 
 In the use of local anesthesia for thyrotomy, the interior of the larynx 
 should be thoroughly cocainized through the direct laryngoscope. This 
 is done with two pairs of operating gloves, one pair being removed after 
 the cocainization so as to lose no time starting the external operation. 
 The skin is now infiltrated as advised for tracheotomy (q. v.). If the 
 stages of the operation are now done with a proper degree of facility, 
 the entire operation can be completed within about ten minutes, and no 
 further anesthesia will be necessary. If a longer time is occupied, it will 
 be necessary to infiltrate the endolarygeal structures with the previously 
 mentioned infiltration solution. The reason for making the endolaryn- 
 geal application is that a nuich more profound effect can be obtained be- 
 fore an incision is made than afterward. It is necessary in the endo- 
 larvngeal application, to use a "■ii» per cent solution of cocaine, and ad- 
 renalin may be added if desired in order to intensify the effect of the 
 cocaine, and also to cause a sharp limitation of the growth, as advised
 
 TKCHNIC OF THVROTOMV I'OU MALU'.XANT DISEASE OF THE LARYNX. Gfi3 
 
 by Sir St. Clair Thomson, ll is necessary to hold the solntion in con- 
 tact for twenty or thirty seconds; simply brushing is not sufficient. Of 
 course the patient must be war.ned that he cannot breathe during this 
 time, and it is necessary to get his confidence in order that he will not 
 struggle or become alarmed. If it is desired to administer chloroform, 
 two methods are available. ( 1 ) The old method with a tampon can- 
 nula inserted through a tracheotomic wound, as the first step in the opera- 
 tion, or using an ordinary cannula and tamponning the trachea after the 
 larynx is open, with a gauze sponge, to which a silk cord is attached. 
 This is pushed down through the laryngeal opening, completely occluding 
 the trachea above the cannula. The chloroform inhalation tube, or, bet- 
 ter, the hand ball insuftlation api)aratus. may be attached to the tracheal 
 cannula for the administration of chloroform. (2) The other method 
 is to have the anesthetist hold a sponge saturated with chloroform over 
 the wound inlerniittently. .Veither of these methods is in any way com- 
 |)arable to the intratracheal insuftlation of ether. A general anesthetic by 
 the ordinary ojjen method is dangerous in any case with even the slight- 
 est dyspnea, but thyrotomy is rarely, if ever, justifiable in any malignant 
 case that is so far advanced as to produce the slightest evidence of 
 dyspnea. 
 
 To forestall excessive coughing the trachea may be punctured and 
 2 cc. of a 2 per cent cocaine solution may Ijc injected into the tracheal 
 interif)r with a hypodermic syringe before incision. 
 
 Operative technic of tliyrotomy. The tecbnic of thyrotomy for 
 cancer, is quite simple. Th.e insufflation catheter being in place, and the 
 patient anesthetized, the operator's headlamp in place, the skin surface 
 being sterilized by the usual iodine method, an incision is made in the 
 skin from the level of the hyoid bone to about the level of the second 
 ring of the trachea. The long incision previously made when a tracheot- 
 omy tul)e was to be inserted, is unnecessary, but, of course, an ample 
 length of incision is always wise in any operation about the neck. The 
 thyroid and cricoid c:.rtilages are (piickly laid bare without elevating or 
 otherwise damaging the outer iierichondrium. It being necessary to re- 
 move the inner pericl;ondrium. the removal of any of the outer perichon- 
 drium would result in chondrial necrosis with consequent laryngeal sten- 
 osis. The thyroid cartilage is split up the median line with the turbino- 
 tome (Fig. HIS ). In making this d\\> with the turbinotome, it is essential 
 in cases of growtlis that are close to the anterior commissure, to make the 
 cut sufficiently to one side to avoid cutting tlirough the growth, in com- 
 pliance with the well known surgical principle that it is necessary to avoid 
 cutting through malignant tissue. I'or this purjiose it is always necessary
 
 66-i TECHNIC OF TIIYROTOMV FOR MALICNAXT DISEASK OF THE LARYNX. 
 
 to have previously made an accurate localization by laryngoscopy, direct 
 or indirect. In some instances, it may be found necessary to split the 
 cricoid cartilage, though, as a rule, this should be avoided. In reopera- 
 tions the old incision must be followed (See Fig. 4l)!M. The lateral wings 
 of the thyroid cartilage are easily spread with retractors, giving a good 
 view of the interior of the lar\nx. The cricoid cartilage, because it is a 
 
 Fin. 488. — Illustration of thjrotomy or laryngofissure. A, shows the line ol 
 incision through the thyroid cartilage. The tubinotome is inserted at the crico- 
 thyroid membrane, the points passing upward (Fig. 468). B, shows retractors 
 placed inside the larynx to hold back the wings of the divided thyroid cartilage. 
 In the median line is seen the insufflation anesthesia catheter. The growth is on 
 the left vocal cord. Perichondria! dissection begins at the divided edge of the 
 thyroid cartilage, the retractor being shifted to the bared cartilage as soon as suf- 
 ficient perichondrium has been separated. It will be noted that the cords do not 
 look like the thin bands seen perorally. They are identified by their position be- 
 low the ventricle. 
 
 complete ring, spreads less easily if partially ossified, as it often is Care 
 must be taken not unnecessarily to injure the divided ends of any of the 
 cartilages, in using retractors or otherwise. 
 
 The most astonishing thing to the operator who opens the larynx for 
 the first time is the totally different appearance of the larynx as compared 
 to the laryngoscopic image. He expects to see two white ribbon-like vocal
 
 TKCIIMC OK TIlVROTdMV I'OK M Al.K'.NANT DISICASK ni" Illi: I.ARYNX. 665 
 
 bands, and instead has great difficulty in identifying- anything resembling 
 a vocal cord. The landmark for which the operator must look is the 
 ventricle. The ridge bounding the ventricle above is the ventricular band, 
 and the ridge bounding it below is the vocal cord. This ridge, of broad 
 base and triangular cross section, has a thick rounded crest and this crest 
 is the vocal cord. (Fig. 488). 
 
 Observation of the size and position of the growth in llie open larynx 
 will determine the plan of excision. The first step will be to plug 
 the pharyngeal orifice with a tethered tampon. In every instance, it 
 is necessary to remove the inner perichondrium, and the incisions of 
 the overlying soft parts must be in the normal widely out fnim 
 the diseased area. The perichondrium is best raised with a periosteum 
 elevator, such as Freer uses for septal work, after a start is made 
 with the knife. Toothed forceps lacerate and do n(Jt hold as well 
 as the author's grasping forceps. (Fig. 470). After the removal of the 
 growth, close inspection of it will determine whether or not a sufficiently 
 wide area of the nfirnial has been removed. If it has not, it is unfortun- 
 ate, but the best thing to do is to excise an additional jiortion of the 
 normal, and if it is found that the initial clipping has been done too close 
 to the growth, it is necessary to attack the opposite side of the larynx 
 and do a perichondria! dissection of a sufficient area. The reason for 
 pcrichondrial dissection is that cartilage and bone as before stated are not 
 readily invoKed, while [jcrichondrium is in some cases attacked by malig- 
 nant disease, and it should be removed though api)arently normal, lest it 
 hf. invaded. Tf it is found that the cartilage itself has been invaded by 
 the mixed pyogenic infections, the case is not one for thyrotomy, and the 
 entire larynx ,'uh1 trachea should be remo\ed, unless it is found, on ex- 
 ploration, that the dec]) lym])hatics of the neck are involved all the way 
 down to the level of the clavicle, in which case it is far better to abandon 
 the operatiim and insert a iracheotomic cannula after remoxing whatever 
 tissue has been detached in the larynx. The jjatient will live longer with 
 the iracheotomic cannula In- way of palliation, than he would if the entire 
 larynx were removed in such a case, for involvement of the deep 
 cer\-ical lymphatics, as mentioned, means almost invari.ably that the 
 mediastinal lymjjhatics arc also involved, rendering comi)lete extirpation 
 impossible. In ])ractically all instances that are adapted to the opera- 
 tion of thyrotomy, the dissection will need to be begun at the divided 
 edge of the thyroid cartilage. The ideal operation is the one in which 
 a relatively large mass of normal tissue is removed with the malignant 
 growth, standing up as an island in the center, with an area of at least 
 Ti mm. fpreferablv more) of apjiarently normal tissue in every direction. 
 Should the growth bv anv mischance be cut through, all instruments that
 
 Olilj TECHNIC OF THYROTOMV FOR MAI.IGNAXT DISEASE OF THE LARYNX. 
 
 have been used in the cutting shoulci not be used again unless resterilized 
 and the growth should be removed with the greatest possible rapidity ; 
 for regardless of our theories as to the infectiousness of cancer, the 
 fact remains that there is a sound basis for the opinion that recurrences 
 in the scar are due to wound infection at the time of operation, cjuite 
 as often as to incomplete removal. Great care should be taken to avoid 
 unnecessary injury to the cricoarytenoid joint because the formation of 
 an adventitious cord, as demonstrated by the author, depends largely 
 upon the traction of the corresponding arytenoid to pull out a new cord 
 from the scar tissue. Obviously, this must not be considered if complete 
 removal of a sufficiently wide area of normal requires removal even 
 of the entire arytenoid, I'.leeding is carefully arrested at each step of 
 the ojieration so as to keep the wound as drv as possible. After the 
 excision of the growth with its normal surrounding tissue, there may be 
 considerable oozing, and in a few instances, it may be necessary to twist 
 or even tie vessels. Ordinarily, however, the bleeding soon ceases under 
 pressure with gauze sponges and the exposure to the air. \\"hen satisfied 
 as to completeness of removal, and all hemorrhage having been stopped, 
 a stitch may be put at the upper ends of the skin incision, if the incision 
 has been rather long. Dr. Patterson and the author are convinced that 
 to make any attempt to stitch together the divided wings of the thyroid 
 cartilage, or the perichondrium covering the outside of the thyroid 
 cartilage, is a great mistake. Every swallowing movement, which is. of 
 course, unavoidable, will separate the cut edges of the thyroid cartilage 
 so strongly that it will tear out any suture that can be placed, result- 
 ing in needless damage to the important laryngeal framework. It is far 
 better for safetv and from every other point of view to pack the wound 
 widely open until the cartilages have united by fibrous union, which they 
 will do in exactly the right position without any stitches whatever, if 
 the patient lie on his back with his head straight almost constantly dur- 
 ing the after-treatment. The method of dressing developed by Dr. Pat- 
 terson, is ideal. (Bib. 20S). A large triple layer of gauze is spread 
 over the wound and the entire front of the neck. A firm roll of gauze 
 is then forced down into the wound pushing ahead of it the triple layer 
 of gauze. (Fig. 47 fi). By this method the wound is kept widely open, 
 and yet there is no risk of any ends of packing getting down into the 
 trachea thus causing irritating cough, or even asphyxia. This gauze 
 should be wrung out of bichloride solution l:li>,0(M), and the dressing 
 should he changed every three hours. Any tendency of the skin to dip 
 down into the wound, must be combated by elevation of the skin edges 
 at each dressing. When the cartilages have united by good firm fibrous 
 union, the wound mav be allowed to close from the bottom. If the
 
 TECHNIC OF TIIVKnTOMV FOR MALIGNANT DISEASE OE THE LARYNX. G67 
 
 larynx is closed, and the skin closed over it, as advised by some oper- 
 ators, not only is there danger from endolaryngeal swelling after pri- 
 mary union of the skin; but, undrained externally, the cartilage will 
 fungate as it always does in healing, and fungations will occlude the in- 
 terior of the larynx and trachea, not only misleading the operator into 
 suspecting recurrence, but the fungations may be so exuberant as to oc- 
 clude the larynx and require tracheotomy, to say nothing of the risks of 
 septic bronchitis from the discharges thrown of¥ by the granulating sur 
 face into the interior of the air passages. Cartilage is slow to heal and 
 it is much slower in the absence of external drainage. 
 
 After-care of thyrotoiuic cases. It is wise to put elevating blocks 
 under the foot of the bed for 4.S hours, and during this time, the patient 
 should lie upon his back with sand pillows on each side of his head in 
 order to keep the head straight in the median line so that there will be 
 no twist on the laryngeal cartilages from traction by the tissues of the 
 neck. After 48 hours, there will be little risk of permanent displacement 
 of the divided thyroid cartilage. Patients sit up in bed on the third 
 day, and get out and move about on the fourth. It is absolutely necessary 
 to have an abundance of fresh air at all times. The windows should be 
 widely open, or better still, the patient should be in a fresh-air room 
 It is absolutely necessary to have nurses skilled in tracheal work in order 
 that the wound shall be dressed every third hour, and also to meet any 
 emergencies that may arise. ( )rdinarily, however, emergencies and com- 
 plications are rare. If the arytenoids and s])hincter are injured and 
 there is no undue reaction and no excision of any ]>art of the upper 
 oritice of the larynx, the patient will have no difficulty in swallowing 
 without leakage. The first test should he made with sterile water, and 
 all foods should be sterile liquids for a week, by which time granulations 
 will protect.* X'ocal rest is necessary. It is, however, not wise to keep 
 the patient silent too loni;, for some vocal eft'orl will prewnt stiffening 
 of the arytenoid joints, and an occasional attempt to sjicak will do no 
 harm, jirovided there are long intervals of rest between. About three or 
 four times a day, the |iatient should ask for any reijuirements. in order 
 to give a few moments use to the laryngeal motor mechanism. After 
 healing of the wcnind the larynx should be examined once a week with the 
 mirror. It is usually best not to remove any little suspicious fungation 
 that may ajjpear after a few weeks. It will he found usually that what 
 appeared to be a recurrence is only a fungating granuloma that will dis- 
 appear spontaneously. Healing is usually complete in three or four 
 weeks. 
 
 •sir FeUx .Semon advises fi-edins the patient in the horizontal position on the 
 operated side, the head hantring .sllRhtly over the edge of the bed.
 
 668 TECHNIC OF THVROTOMV FOR MALIGNANT DISEASE OF THE LARYNX. 
 
 Modifications of the foregoing technic. The foregoing, is, in brief, 
 the method of operation and of after care followed by Dr. Patterson and 
 myself. We do not use a curette because if it remove any infected tis- 
 sue, it will simply stir the infection about and implant it in the soil to 
 cause a recurrence, later. If it remove no infected tissue, it is unneces- 
 sarv to use it, and as compared to a clean cut, it leaves a surface which 
 is slower healing. No other plan than clean cutting is, in our opinion, 
 satisfactory. The use of the galvano-cautery knife for the excision of 
 malignancy elsewhere has proven advantageous ; and may, e\entually 
 prove satisfactory for larj'ngeal malignancy. ( )perators, who prefer 
 general anesthesia and are without an intratracheal insufflation ether 
 apparatus, do a preliminary tracheotomy as low as possible and insert 
 an ordinary tracheal cannula through which the anesthetic is given. 
 The Hahn and Trendelenberg cannulae are no longer used. Instead, 
 after the larynx is opened gauze packing is firmly placed down in the 
 trachea above the cannula to prevent trickling down of blood antl secre- 
 tions. 
 
 Coniplications. Necrosis of cartilage with subsequent stenosis may 
 result from damaging the cartilage of both perichondria, or from inser- 
 tion of stitches, both of which are avoidable. In case of reoperations an 
 island of cartilage may die if the line of fibrous union of the previous 
 incision be not followed as mentioned under '"Laryngostomy"' (Fig. -469). 
 Lung complications after thyrotomy by the methods herein given are 
 exceedinglv rare.
 
 CHAPTER XLV. 
 
 Technic of Laryngectomy. 
 
 Preparation of the patient is the same as for thyrotoniy. 
 
 Position of the patient. As advised for thyrotoniy the best position 
 of the ])atient is a combined Trendelenberg-Rose ])osition. The incHna- 
 tion of the tal)le need not be extreme if the intratracheal insuttiation 
 anesthesia be used 
 
 Anesthesia. It is quite feasible to remove the larynx with local 
 anesthesia, by infiltrating first the skin and then the deeper tissues as 
 they are approached. But much o[)erative time will be saved and shock 
 diminished by intratracheal insuffiation anesthesia. It this be not used, 
 the only safe wa\- of using general anesthesia without prolonging the 
 oiieration is to administer the anesthetic through a preliminarily inserted 
 tracheal cannula. A gauze sjionge is kept saturated continuously by very 
 small drops of ether as advocated by Ferguson. I'nder no circumstances 
 should etherization be attempted by the ordinary method through the 
 mouth if there is the slightest degree of dyspnea, for reasons given in 
 Chapter XXX\'II. If the operation is done by the Keen or Gluck meth- 
 ods, from above downward without tracheotomy, the insufllation is start- 
 ed with the catheter inserted through the mouth in the usual way. When 
 the stage is reached where it is desired to draw the laryn.x forward. 
 a fresh sterile insufilation catheter can be inserted into the upper orifice 
 of the larynx and the anesthetic thus continued until the trachea is ampu- 
 tated, when the catheter is removed and a fresh one inserted into the lower 
 trachea after the remo\al of the ;im]iutated larynx. 
 
 Operative teehnie of larynyectomy. Two classes of procedure have 
 been followed. In one the extirpation of the larynx, without tracheo- 
 ti>ni\'. begins aiio\e. at the th\rohyiiid nieiiibranc, the larynx being drawn 
 forward as il is separated from ilie jjarty wall, and the amputation from 
 the trachea being done when sufticient of the larynx and trachea have 
 been thus dissected loose and dr;u\'i nut. |)uring the operation the
 
 670 
 
 TIXHNIC OF LAKVNGKCTOMY. 
 
 Fig. 489. — Schematic illustration of laryngectomy with the aid of intra- 
 tracheal insufflation anesthesia. At i .is shown the trachea and larynx exposed 
 during anesthesia administered with the Elsberg apparatus through the silk-woven 
 catheter, C, held in place with the Janeway bite block D. The incision has been 
 made of T-shape, as will be understood by the sutured wound in 4. The trachea 
 is elevated forward by means of the grooved director inserted carefully between 
 the trachea and the esophagus. Two anchor sutures are inserted around the 
 first ring of the trachea as shown at A, B, after preliminary incision of the 
 intcrannular membrane. 
 
 2. The trachea has been severed between the cricoid and the first ring, 
 drawn forward, and firmly fastened with the anchor sutures (A, B) at S. A 
 fresh insufflation catheter (C) has been inserted for the continuation of the 
 anesthetic. The larynx has been dissected free from the esophageal wall (E) 
 and is held forward with the forceps, F. 
 
 3. The scissors are shown dividing the cornu of the thyroid cartilage. The 
 pharyngeal wall has been divided so as to free the larynx posteriorly and this 
 clipping will be continued around over the front so as to free the entire larynx, 
 by severing the thyrohyoid membrane. 
 
 4. The wound is stitched together througliout its entire extent after sutur- 
 ing the pharynx, putting in supporting sutures, and securely anchoring the tra- 
 chea to the skin (Modified from Molinie).
 
 TIXIIMC OI" I.ARVXGKCTOMV. 671 
 
 anesllietic, which has heen started thrnni^'li the nioiUh, is given through 
 the oiitdrawii larynx. The other method i.s used after prelinnnary 
 tracheotomy. The trachea i.s dixided below the cricoid and the laryn.x is 
 dissected away from the party wall by working upward from below. (Fig. 
 489). 
 
 The author prefers to do a preliminary tracheotomy about a week 
 beforehand so as to permit firm adhesions between the trachea and the 
 soft tissues of the neck to anchor the trachea firmly, thus avoiding the 
 tendency to retraction within the thorax, when the trachea is afterwards 
 cut off and stitched to the skin. The inflammatory adhesions in the 
 neighborhood of the trachea close various avenues by which infection 
 could find its way into the mediastinum, and this barrier can be increased 
 as desired by a blunt dissection around the sides of the trachea. (3ne 
 week later, the trachea is amputated (as low as previous bronchosco]n- 
 has indicated) through a T-shajied incision, the transverse portion of 
 which is at about the level of the thyroid notch, the vertical portion ex- 
 tending;- diiwnward as far as may be needed, liul preferably not into the 
 preliminary tracheotomy wound. The traclieal end of the larynx is 
 raised very carefully without undue traction ui)on the esophagus, and is 
 carefully freed from the esophagus from below upward, until the aryte- 
 noids are reached. Tiie vagi and the parathyroids should be carefully 
 avoided, especi;dly the latter. The author has a number of times re- 
 moved wilboul ill effect part of one vagus when it w-as suspiciously 
 close to the in\'olved area. The pharyngeal wall is carefully cut away 
 with the scissors, being careful to save all of the mucosa and submucosal 
 tissues possible, in order to make the strongest possible wall when the 
 [iharynx is sutured after removal of the larynx. Usually the tips of the 
 horns of the thyroid cartilage are cut off and left. The thyrohyoid mem- 
 brane is incised and the aryepiglottic folds are clipped free with the 
 scissors. .Ml hemorrhage is carefully arrested at each stage of the opera- 
 tion ; a clean, drv wound being essentia! to acctirate work. The pharynx 
 is now sutured with silk, being careful not to jierforate the mucosa, the 
 edges of which are inverted. Then each layer of the soft tissue is care- 
 fully stitched into place so as to afford the greatest possible support to 
 withstand the strain of deglutitinn. I'.efore stitching the skin, the Els- 
 berg insufflation catheter, or the anesthesia cannula, either of which, up 
 to this time, has been in place in the preliminary low tracheotomy wound, 
 is removed and the ciU end of the trachea above the old tracheotomic 
 wound is brought forw^ard and inserted through a button-hole in the skin 
 below the laryngcctomic incision. Tf this incision has been so long as to 
 extend into tlic tracheotomic skin incision, this part of the incision 
 must be verv carefullv and tirmly stitched with tension sutures deep as
 
 C72 
 
 TECH NIC OF LARVN'CKCTOMY. 
 
 well as superficial. The trachea is then stitched all around to the skin 
 surface. The preliminary tracheotomic incision is drained by a wick of 
 gauze inserted into the old wound below the new tracheal orifice. The 
 skin is then accurately stitched and a large gauze dressing wrung out of 
 mercuric bichloride 1 :10,000 is applied. 
 
 As with malignancy, everywhere, it is useless to do a laryngectomy 
 and leave involved glands in the neck. The most favorable time for the 
 removal of the glands is at the preliminary tracheotomy, because a 
 rather extensive neck dissection at that time has the advantage of form- 
 ing a barrier against infection of the mediastinum at the lar}-ngectomy 
 later, and if the glandular involvement is such that there is reason to be- 
 
 Fig. 490. — Plastic operation for repair of the esophagus after verj- extensive 
 esophageal resection at laryngectomy. The two upper flaps are turned epidermal 
 surface inward. Ordinarily the pharyngeal walls can lie drawn together without 
 tliese autoplastic dermal flaps. (After Molinie.) 
 
 lieve that the mediastinal glands are also infected, it is better to abandon 
 all hope of cure and leave the tracheotomy tube in or not, according to 
 conditions. If d3^spnea is present at all, it is better to leave the tube in, 
 for it will shortly be required, and it is better done early than late The 
 iiistologic examination of suspicious lymph nodes is always advisable. If 
 a lymph node taken from near the upper thoracic aperture shows malig- 
 nant involvement, laryngectomy is rarely, if ever, justifiable. The author 
 has in a number of cases been able to discover malignant nodes along the 
 side of the party wall, and in the mediastinum by esophagoscopy (q. v.). 
 After-care. Antibechics and all opium derivatives must be forbidden. 
 Feeding should be bv a soft rubber catheter or very small stomach 
 tube passed through the mouth. Plenty of fluid must be given. The 
 external dressings are renewed every three or four hours, because it 
 is impossible to prevent their lieing soiled bv the contiguous tracheal
 
 TKCHXIC OF LARYNGECTOMY. fi73 
 
 oi)eniiig. The tracheal dressings are of sejjarate pieces of gauze, re- 
 newed as ad\i<e(l under tracheotomy. The tracheal cannula is kept in 
 place in the end of the amputated trachea, but as the latter is stitched 
 to the skin there is no wound to pack open. The wick of gauze in the 
 lower end of the laryngectomic incision is removed and renewed with 
 the (h'essings every three hours, and discontinued when drainage is no 
 longer needed. If the ]5haryngeal wound break down, the lower stitches 
 of the skin wound must be opened and free drainage of pharyngeal secre- 
 tions by fresh dressings inserted every hour. 'Jlie patient should be 
 prop.ped up in bed on the second day and gotten out of bed on the fourth 
 or filth (lav. Ordinarilv the feeding tube may be abandoned and the 
 patient permitted to swallow strained sterile lic|uid food in small sips 
 at the end of a week or ten days. 
 
 Esophageal resection. If removal of much of the anterior esophageal 
 wall is rei|uired autoplastic repair with dermal flaps (Fig. 490) may be 
 rec|uired. The esophagus is, surgically, one of the most intolerant organs 
 in the body : and, moreover, recurrence of malignancy is almost certain. 
 Therefore esophageal resection is rarely advisable. 
 
 The dermal flap operation (Fig. 4!I0) is best adapted to female pa- 
 tients. In males, hair from the epidermal flaps may require frequent 
 endoscopic removals. 
 
 Complications. ()perative complications are now relatively rare. 
 Streptoccemia and jjulmonary comi^Iications which by older methods 
 were so frequent are now seldom seen. Profound shock, weak and rapid 
 pulse, slight temijerature elevation, ])rofound depression, white or ashy 
 gray com])lcNion, out of all i)roportion to the usual post-operative re- 
 action are symptoms denoting acute esophagitis, vagitis or sejjtic medias- 
 linitis. Beyond stimulants and Incal drainage of necrotic areas, treat- 
 ment is of little avail. 
 
 .liiilicidt laryiLV. .Must patients abandon the use of a iirothetic 
 aiijiaratus and devote themseh'cs to the de\'eloi]nient of a buccal \()ice. 
 The most satisfactory apparatus is that of Sir Robert Woods of Dublin. 
 Next to this in eiricicncv is that of (iluck.
 
 CHAPTER XLVI. 
 
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 •-)7. BuLSOx, .Vi.1!i:kt E.. Jh- P)ronchoscopy and Esophagoscopy. 
 Jour. Ind. State Med. .Assn.. \ol. \7. Xo. 4. April l-"), 1!)13, p. l.~,0. 
 
 ■).S. I!i"RCK!i.\RDT, A. S. Tuberculosis of the Esophagu.^. Arch, 
 f. \ erdanungs-Krankh.. .Vug., li)lo. 
 
 .->!>. Bi^TLix, Hexkv T. Ojjerations for Cancer of the Larynx. 
 Journal of Laryngology. Rhinol. and ()to!., 1 90S. 
 
 <>0. lU'Ri'.KK, H. l'"in 'i'lXlHch \crlaufcncr i'lronchoskopischer 
 Fremdkor])erfa]l. Ztschr. f. Laryngol.. Pbinol. u. ihre Cirenzgebietc, I'.d. 
 1, p. 785, lilUD. 
 
 fiL Bronnhik, Adolimi. Fissure of tlie Mouth of the Esophagus. 
 Brit. Med. Journ.. Oct. li), l!>Iv^ 
 
 <'<2. UruiCxixcs, W. Die Direktc Laryngosko]jic, Bronchoskopie 
 un<l ()eso]ihagoskopie. Text book. Pub. by J. F. Bergman Wiesbaden. 
 
 <i:5. BuTLix, vSir Hkxrv. Indications for Early Radical Treat- 
 ment of .Malignant Disease of the Larynx. Brit. Mctl. Journ., Oct. 2''<, 
 IS!).-;. 
 
 (ii). C.\RPEXTi:r, E. ^^ . r.roncho-Esophagosco])y. The Laryngo- 
 scope, May, 1!)]4. 
 
 TO. C.XRPKXTi-.K. !*".. W. Death of Infant Caused by Fragment of 
 Peanut in the l^ung. The Laryngoscope, March, liH I. 
 
 7L C.\i'z.\Ri), ]'. ( )esopliagoscopic. .\rcli Inlcrnat dc Laryngol. 
 etc.. .\X\'. ]). lilllii. PMiS. 
 
 72. Cauz.xki), I'. ( )esophagoscopie ct Tracheoi)ronc]ioscopie. 
 Rev. hcbd. de Laryngol., p. 117, 1i)0S. 
 
 LI. C.\rpi;nti;r, E. W . I'lronchoscoiiy. Journ. S. Car. .Med. .Assn., 
 \'oi. \III, Xo. S, Aug., DP.', p. 2->->. 
 
 7 1. Carki:i„ .\. ICxpcrimcntal Tntrallioracic Surgery by the iMell- 
 zer and .\ucr Method of Luratrachcal hisul'llation. Med. Record, March 
 111, i:i|o, ;in(l i'.rrl. KUn. Wcbnsclu-., March -.'S, lUlo.
 
 G78 BIlilJOGRAPIIY. 
 
 73. Casselberry, \\'. E. The Cutting in Two of a Large Steel 
 ]'in, while Transfixed in the Left Bronchus and Its Removal by Lower 
 Bronchoscopy. Transactions Amer. Laryngol. Soc, 1910. 
 
 7(>. Castex. Total Laryngectomy in the Practice of Prof. Jeannel. 
 (La Laryngectomie Totale dans le Service de M. le Professeur Jeannel). 
 These de Toulouse, 1!)10. 
 
 77. Chappel, W. F. Early Diagnosis of Malignant Disease of the 
 Larynx. N. Y. Aled. Record, Oct. Ki, lUO'J. 
 
 78. Chapman, G. H. Some Different Terminations of Foreign 
 Bodies in the Wind-Pipe. L'ville Monthly Journ. of Med. and Surg., 
 June, 1910. 
 
 7il. ChauvEau. C. Cannula Used and Broken in the Trachea. (Ca- 
 nule usee et beisee dans la trachee). Arch, internat de Larvngol. 
 d'Otol. et de Rhinol., Jan.-Feb., 1910. 
 
 80. Chenerv, W. E. Case of Paralysis of the Left \ ocal Cord 
 Caused by Peritracheal Tumor. The Laryngoscope, Jan., 1909. 
 
 81. Chiari, O. Death in Case of Superior Bronchoscopy. ( Ein 
 Todesfall bei der Bronchoscopia Superior). Monatschr. f. Ohrenh. u. 
 Laryngo-Rhinol., Bd. 41, Heft. 8, 1910. 
 
 X2. Chiari, O. Two Cases of Foreign Bodies Removed by 
 Bronchoscopy Several Years after their Entrance. (L'eber zwei Falle 
 von Fremdkorpern welche mehrere Jahre nach ihrem Eindringen 
 Bronchskopisch entfernt wurden). Monatschr. f. Ohrenh. u. Laryngo- 
 Rhinol., Heft 1, 1910. 
 
 83. CiSNEROs, Juan. Results of Operative Treatment of Laryn- 
 geal Cancer. ( Resultados del tratamiento operatori del cancer lar- 
 ingo.) Bol. de Laringol., Otol. y Rinol., May- August, 1910. 
 
 84. Claque, R. Study of Foreign Bodies in the Esophagus and 
 Bronchus. Gaz. hebd. des Sci. med. de Bordeaux, March 20. 1910. 
 
 85. Clarke, Thomas Wood and Marine, David. Pulmonary 
 Gangrene following Foreign Bodies in the Bronchi. Med. and Pathologi- 
 cal Services of the Lakeside Hospital. 
 
 8(5. Clark, J. Payson and Richardson, Oscar. Case of Foreign 
 Body in the Trachea. Status Lymphaticus. Death. Autopsy. Boston 
 :\led. and Surg. Journ.. Jan. 2(i, 1911. 
 
 87. Cocks, Gerhard Hutchison. Status Thymo-lymphaticus and 
 its Relation to Sudden Death. The Laryngoscope, St. Louis, July, 191(i. 
 
 88. CoMPAiRED. Nos Interventions dans le Cancer du Laryn.x. 
 Arch. Internal, de Laryngol., d'Otol. et de Rhinol, March. 1909. 
 
 89. CooLiDGE, A., Jr. Annals of Otology, Rhinology and Laryn- 
 gology, Dec, 190fi. (Also Proceedings Am. Laryngol. Soc, 190(i. )
 
 BIIiLIOGRAPHV. 679 
 
 90. CoLK. Demonstration of X-Rav Plates of Esophagus, Stomach 
 and Colon. Post-Ciraduate, April, litlu. 
 
 ill. CriliC, Gko. W. The Identity of Cause of Aseptic Wound 
 Fever and So-Called Post-Operative Hyperthyroidism and their Preven- 
 tion. Read before the So. Surg, and Gyn. Ass'n., Dec. IT, }'.>]•>. 
 
 !I2. Cui.p, J. F. Foreign Body in the Broni^hus. Proc. Amer. 
 Laryngol. Rhin. and Otol. See. l!)i;), p. 318. 
 
 !>•■). Cole, L. G. Localization of Foreign Bodies. Med. News, 
 .March 15, 1002. 
 
 !H. Co.\KLiiv, Cornelius G. Foreign Bodies in the Esophagus. 
 Trans. Am. Laryngol. Ass'n., 1913. 
 
 9"). Co.VKLEY, Cornelius G. Fatal Case of Asphyxia. Trans. Am. 
 Laryngol. Ass'n., T.iln. ( \ery interesting as bearing on "status lympha- 
 ticus.") 
 
 9(5. CoATEs, George M. jackstones in the Esophagus. Arch. 
 Pediatrics, Aug., 19M. 
 
 100. Davis, Edwaud D. Relief of Pain of Laryngeal Tuberculosis. 
 Lancet, Oct. 18, 1913. 
 
 KH. Da Costa, John C. Modern Surgery. (Text book pub. by 
 Saunders & Co.) 
 
 102. Davis, EnwARo 1). Observations on Susjiension Laryngos- 
 copy, with the Notes of a Few Cases. I'.ritish Med. Jour. No. 2710, 
 Jan. 18, 1913, p. 115. 
 
 103. D.wis, H. J. Case of Laryngeal \'ertigo. Jour, of Laryngol., 
 Khinol. and Otol.. March, I'HO. 
 
 104. D.wis, J. L. Laryngeal Neoplasms. The Laryngoscope, May, 
 1908. 
 
 105. Davis, J. ]^. Laryngeal Neoplasms — A Later Review. The 
 Laryngo.scope, Ajiril, 1910. 
 
 100. Dei.alande, H. Dc la Gastroscopie. Pub. by lnii)rimerie 
 JCommerciale 50 Rue du llautnir, Bordeaux. In collaboration wilb E. J. 
 ^loure, 1908. 
 
 107. Delavan, D. I'.RvSdN. Foreign Bodies in the .\ir Passages. ^, 
 Reference Handbook of the Meilicil Sciences, \ol. 1, p. 168. 
 
 108. Del.wan, D. Brvson, and John Roceus. Treatment of 
 Chronic Laryngeal Stenosis. Transactions Am. Laryngol. Soc, 1905. 
 
 109. Delavan, D. Bryson. Inlub.ilion in Chronic Stenosis of the 
 Lj.rynx. Med. News, March 19, 1S98. 
 
 110. Dki.avan, D. Brvson. Treatment oi Cicatricial Stenosis of 
 the Larynx. Journ. Laryngology 1909, Nov., p. 585. 
 
 111. Dki.avan, D. Brv.son. Treatment of Cicatricial Stenosis ot 
 the Larynx. Laryngoscope, Nov., 1909.
 
 680 BIBLIOGRAPHY. 
 
 113. Denkkr, Ali'REd. Tracheobronchial and I'uhnonary Syjiliihs 
 Diagnosed by Means of the Bronchoscope. Deutsche Med. \\ och., Xo. 
 1, Jan. 4, liilS, p. 11, 
 
 llo. Dennis, F. L. Laryngeal Fissure for Intrinsic Laryngeal 
 Carcinoma. Colo. IMed., June, 1909. 
 
 IIL DuPUY, Homer. (1) Foreign Body in the Esophagus Re- 
 mc\ed by Esophagoscopy ; (2) Foreign J!ody in Bronchial Tract. New 
 Orleans Med. and Surg. Journ.. May, BU:! — hXV — 815. 
 
 115. DowNiE, \\'alker. Syphilis as a Cause of Esophageal Stenosis. 
 Brit. Med. Journ. Oct. 19, 1913. 
 
 110. Del-WAN, D. Brysqn. Withholding of Reports of Opera- 
 tions for the Relief of Cancer of the Throat. New York .Med. Journ., 
 Oct. 14, 1893. 
 
 117. Deeavan, D. Bryson. Primary Epithelioma of the Epiglot- 
 tis. 
 
 118. Dia.-WAN, D. Bryson. Statistics for Relief of Malignant Dis- 
 ease of the Larynx. 
 
 125. Elsberg, Chas. a. Anesthesia by the Intratracheal Insuf- 
 flation of Air and Ether. Annals of Surgery, Feb., 1911. 
 
 126. Eesberg, C. a. Value of Continuous Intratracheal Insuffla- 
 tion of Air (Meltzer) in Thoracic Surgery; \\'ith Description of an Ap- 
 paratus. Med. Record, March 19, 1910, and Ann. of Surg., July, 1910. 
 
 12T. Elsberg, C. A. and LiliEnth.\l, H. General Anesthesia by 
 Means of Meltzer's Continuous Intratracheal Insufflation, fieri. Klin. 
 Wchr., May 2:5, 1910. 
 
 128. Elsner, H. Gastroscopie, 1911. Pub. by George Thieme, 
 Leipzig. 
 
 129. Ephraim, a. The Importance of Bronchoscopy in Internal 
 Medicine. Bed. Klin. Wchnschr., Oct. 25, 1909. 
 
 130. Ephraim, A. C. ( Breslau. ) Anesthesia in r.ronchoscopy. 
 Arch. Intern, de Laryngol. d'Otol. et de Khin., May-June, 1912. \'ol. 
 XXXIII, No. 3, 690. 
 
 131. Epeiraim, a. Endobronchial Therapy. I'.erl. Klin. 
 Wchnschr., July 4, 1910. 
 
 132. Ephraim. Significance of Bronchoscopy for Internal Medi- 
 cine. Deut. med. Wchnschr., No. 5, 1910. 
 
 133. Ephriam, a. Local Treatment of Chronic Bronchial Dis- 
 eases. Arch. f. Larj'ngol. u. Rhmol, Bd. 24, Heft 1. 19in, and .\rch. 
 Internat. de Laryngol. d'Otol. et de Rhinol, Nov.-Dec, 191 (i. 
 
 134. Emerson, Linn. Perforation of Esophagus and Aorta by a 
 Chicken Bone. Discussion. Proc. Amer. Laryngol., Rhinol. and ( )tol. 
 Soc, 1913, p. 321.
 
 EIKLIOGRAPUY. 681 
 
 135. EuiNC.Tox. Abstract Ly Guthrie. Congenital Occlusion of 
 the Esophagus. Laryngoscope, Jan., Iiil4. 
 
 144. F-\ULDKR, T. Jefi'Eksox. Direct Esophagoscopy. IJrit. Med. 
 Journ., Aug. ^7, I'JIO. 
 
 145. Ferrkri, G. Technic of Tracheobronchoscopy. The Laryn- 
 goscope, April, 11)10. 
 
 14(). Forbes, Henrv H. Direct Laryngoscopy. Post-Graduate, 
 Vol. XXVIII, No. 1, Jan., 1!)13, p. 28. 
 
 147. Foster, H. Report of Two L'nusual and Interesting Cases of 
 Acute Edema of the Larynx. The Laryngoscope, St. Louis, Feb. 1910. 
 
 148. FouRXiER, G. Contribution I'Etude de la Dilatation Caout- 
 choutee dans la Laryngostomie. Rev. hebd. de Laryngol., d'Otol. et de 
 Rhinol., Oct. !), 1U09. 
 
 149. Eraser. J. S. Direct Laryngoscopy, Tracheobronchoscopy 
 and Esophagoscopy. Edinburg Med. Jour., \'ol. X, Xo. 1, Jan., 1913, 
 p. c. 
 
 150. Fresc. Traction Diverticula of the Gullet Diagnosed by Eso- 
 phagoscopy. Monatschr. f, ( )hrenheilk., Xov., 1911, p. loJJ3. 
 
 151. FuEUDEXTiiAi., WoLEi'. Personal Observations with Sus- 
 pension Laryngoscopy. Medical Record, February 22, 1913. 
 
 152. Freudenthae, W. Endobronchial Treatment of .\sthma. xN. 
 Y. Med. Journ., June 24, 1911. 
 
 153. Frecdjcxtiiae, W'oefe. The Removal of Foreign Bodies from 
 the Esophagus and the lironchi with the Aid of the Fluoroscopic Screen. 
 Intern. Journ, of Surg., Sept., 1910. 
 
 154. FrEudEntiiae, Wulee. A Plea for Systematic Use of llron- 
 choscopy in Our Routine Work, with Descrii>tion of a Modified I'ron- 
 choscope. X. V. Med. Journ., May 23, 1908. 
 
 155. FriEdberg, S. a. Bronchoscopy and Esophagoscopy. Illinois 
 Med. Journal, March, 19J1. 
 
 166. Garel, J. Cancer du Larynx Siegeant sur le Re[)li Arylcno- 
 epiglottique Gauche; Operation Endolaryngeal ; Gucrison. Rev. hebd. 
 de Laryngol., d'Otol. ct de Rhinol., Sept. 18, PI09. 
 
 Jli7. Gaub, O. C. and Jackson, C. Bronchoscopic Aid in Thora- 
 cotomy. The Laryngoscope, Feb., ]!*10. 
 
 168. Geeitsmann, J. Cordcctomy for I'.ilateral Abductor i'araly- 
 sis with Demonstration of Specimen. The Laryngoscope, April, 1910. 
 Arch. f. Laryngol. u. Rhinol., Vol. 23, Heft L 1''10, and Arch. Internat. 
 de Laryngol. d'Otol et de Rhinol., March-April, 1910. 
 
 169. Glucksmann, George. The Xewer Methods of Extraction 
 of Foreign Bodies from the Upper .Air and Food Passages. Berl. Klin. 
 W'ocli.. Xl.lX, Xo. 2;!, June :!, 1912. p. PLSl.
 
 682 DIKLIOGRAPHV. 
 
 170. GoLDBACH, L. J. Direct Laryngo-Tracheo-Bronchoscopy and 
 Esophagoscopy. Report of Cases. The Laryngoscope, Sept., I'JIO. 
 
 171. Goldstein, M. A. Lipoma of the Larynx. The Laryngo- 
 scope, 1909. (Excellent resume of the subject.) 
 
 172. Gray, A. L. Remarks on X-Ray Technic in the Treatment 
 of Laryngeal Papillomata in Children. Ann. of Utol., Rhinol. and Laryn- 
 goL, June 25, 1910. 
 
 173. Greene, D. C. Laryngotomy and Laryngectomy for Cancer. 
 Boston Med. and Surg. Jour., Jan. 28, 1909. 
 
 174. Green, A. S. and Lack, H. L. Subglottic Laryngeal Tumor. 
 Proc. Soc. Aled., \'ol. 1, No. 8, 1909. 
 
 175. Grifeith, J. P. C. and Lavenson, R. S. Case of Congenital 
 Malformation of the Esophagus with Report of a Case. Arch, of 
 Pediatr., March, 1909. 
 
 176. Griswold, W. C. Five Cases of Foreign Bodies, for which 
 Bronchoscopy or Esophagoscopy was performed. Post-Graduate, Vol. 
 XX Vn, No. 5, May, 1912, p. 397. 
 
 177. Grove, W. E. Tracheobronchoscopy in Diagnosis and Tr^at- 
 mtnt. Wisconsin Med. Jour., \'o\. XI, No. 11, April, 1913, p. 346. 
 
 178. GuiSEz, J. Maladies de 1' Esophage. Paris, 1911. 
 
 179. GutSEZ. New Cases of Diagnosis by Means of Direct Laryn- 
 goscopy not Possible with RTirror. (Neue Falle von Diagnosen mit- 
 tels Direkter Laryngoskopie die mit dem Spiegel nicht Gestellt werden 
 Konnten.) Ztschr. f. Laryngol. Rhinol. u. ihre Grenzgeb., Bd. 2, Heft 6, 
 1910. 
 
 180. GuiSEz and Abrand. Physiology of the Esophagus. .\nn. 
 des Mai. de I'Oreille, du Larynx, du Xez et du Pharynx, Sept., 1910. 
 
 181. GuisEz. Two L'nusual Cases of Tuberculosis of the Esoph- 
 agus Diagnosed and Treated by Esophagoscopy. Gaz. des Hopit., 
 March 8, 1910. 
 
 182. GuiSEz. Removal by Bronchoscopy of Foreign Bodies in 
 Bronchi of Two Infants. Bull, de La Soc. de Ped., June, 1910. 
 
 183. GuiSEZ. Broncho-Esophagoscopy in Diagnosis of Aneurism 
 of the Aorta. Arch, des Mai. du Coeur, etc., April, 1909. 
 
 184. Guthrie, Thomas. Twelve Cases of Foreign Body in the 
 Larynx and Esophagus, in Most of Which Removal \\'as Effected by 
 Direct Endoscopy. Liverpool Med. Cliir. Journ., Jul\-, 1912, No. (i2, p. 
 459. 
 
 1S5. Goldstein. M. A. Discussion on Foreign Bodies in the 
 Trachea. Proceedings .Am. Lar., Rhin. and Otol. Soc, 1913, p. 388. 
 
 186. Green, Nathan W. An Esophagoscope with Direct Outside 
 Illumination. Annals of Surgery, Feb., 1914.
 
 BIBLICH-.KAl'UV. 683 
 
 194. Harris, Thomas J. Radium for Papilloma of the Larynx in 
 Children. Proceedings International Medical Congress, London, 1913. 
 
 li>5. Halstkd, T. H. Practicality of Bronchoscopy and Esophagos- 
 coi)y. The Laryngoscope. July, 190!'. 
 
 i\H>. Haret and Jauckas. Tumor of the Trachea Cured by Radio- 
 therapy. Soc. of Radiol., May 11, 1909. 
 
 197. Hausted. Asphyxia Caused by the Lumbricoid Ascarides in 
 Trachea. Hospitalstidende. May 18. 1910. 
 
 198. H.ws, Haroi.d. The Pharyngoscope. The Laryngoscope, 
 July, 1909. 
 
 199. HiCKEY, P. M. Foreign I'.odies in the Esophagus and Lower 
 Air Passages. Jour. Mich. State Med. Soc. Jan., 1910. 
 
 200. Hill, \\ illl\m. On Gastroscopy, 1912. Pub. by John Bales 
 and Sons and Danielson, Oxford St., London. 
 
 201. Hill, William. On Gastroscopy: A Plea for its Routine 
 Employment by Gastric Experts. Brit. Med. Journ., Oct., 1911, p. 1074. 
 
 202. HoLixGER, J. Papilloma of the Larynx Combined with Open 
 Foramen Ovale in Heart. Trans. Chicago L. and O. Soc, May 17, 1910. 
 
 203. H0PKIN.S, F. E. A Case of Multiple Foreign Bodies in the 
 Smaller Bronchi. .\nn. of Otol,, Rhinol. and Laryngology, Vol. XX, 
 No. -1, Dec, 1911, p. 82,"). 
 
 204. Horand. Total Laryngectomy for Syphilitic Stenosis of 
 Larynx. Lyon Med., July 24, 1910. 
 
 20.3. HoRNE, W. J. Specimens showing the Pathogenesis of Pachy- 
 dermia Laryngis \'errucosa et Diffusa. Proc R. Soc. Med., Vol. 1, No. 
 9, 1909. 
 
 20G. ITiiKx, Henry. The Bronchoscojiic Treatment of Bronchial 
 Asthma. Read in the Section on l^aryngology and Otol. of the A. M. A. 
 at Cist Annual Session held at St. Louis, June, I'.tlo. 
 
 207. HoRSLEY, J. S. Suture of Recurrent I^aryngeal Nerve with 
 Report of a Case. Trans, of South. Surg, and Gynecol. Ass'n., Dec, 
 1909. 
 
 208. HnwARTH, W. G. Direct Laryngoscopy, llronchoscopy and 
 Esophagoscopy. (Translation of Briinings' text book.) 
 
 209. Hubbard, Thomas. Esophagoscopy and I'.ronchoscopy ; Re- 
 ports of Cases of Foreign Bodies in the Esophagus and r.ronchi Operated 
 by the Killian Method. Transactions of the .Vmer. Laryngol. Assn., 1911. 
 
 211). Ih;iii;u, h""RANCis. Removal of Foreign I'.odies from the 
 Bronchi. Surg. Gyn. and Obstetrics, May, 1910, pages .524-.-)29. 
 
 2n. TL'NT, John G. (Fort William.) Report of a Case of 
 .\s|iiration of a Silver Traclieotomy Canimla Removed by Lower Bron- 
 choscopy. Canadian Med. Ass'n. Journ., \ ol. .\1, No. •">, May, 1912, 
 p. 414. Also Annals Otol., Rhinol. and Laryngol., June, 1912, p. 355.
 
 G84 BIDLIOGRAPHV. 
 
 •<;i'.'. HowARTii, \\". G. Foreign I'.odies in tlie Air Passages. 
 Lancet, ( )ct. -1, 1913. 
 
 ■-'l-'i. HiLi,, W'm. Idiopathic Spasm of the Esophagus as a Com- 
 mon Diagnostic Error. Journ. Laryngol., Rhinol. and Otol. ( X'ery in- 
 teresting discussion.) 
 
 214. HERYNG, TiiEodork. Laryngeal Arthritis. (Gosiec Krtani) 
 Mcdycyna, No. 20, 1910. 
 
 21."). Heryno, Theodore. Soft Rubber Dilatation of the Stenosed 
 Larynx. Discussion Proc. Ele\enth Liternat. Med. Congress. Rome. 
 lS9t. 
 
 21 li. How.XKD. C. P. Etiology and Pathogenesis of Pronchiectasis. 
 .Amer. Journ. Med. Sciences, March, Pil4. 
 
 219. Jngersoll, J. M. Primary Malignant Growth of the Trachea. 
 Transactions Amer. Laryngol. Soc, 1914. Also Annals Otol.. Rhinol. 
 Laryngol., June, 1914. 
 
 220. IwANuEi", A. Technic of I^aryngostomy. Ztsclir. f. Laryn- 
 gol. Rhinol. u. ihre Grinzgeb., Bd. o, Heft 2, 1910. 
 
 221. Iglauer, Samuel. Electro-Magnets in the Extraction of 
 Foreign Bodies from the Trachea and Bronchi. Proc. .Am. Acad. ( )i)thal. 
 and Oto-Laryngol., 1913. 
 
 222. Iglauer, Samuel. Three Cases of Foreign Body in the 
 Bronchi. Lancet-Clinic, Vol. CII. Xo. 22, June 1, 1912. 
 
 223. Igl.\uER, Samuel. Tracheobronchoscopy — With Report of 
 Cases. Ohio State Med. Journ., April, 1911. 
 
 224. IGL.A.UER, Samuel. Foreign ISody in Larynx and Trachea 
 Removed by the Aid of the Suspension Laryngoscope. The Laryngo- 
 scope, June, 1913. 
 
 225. Ingals, E. F. Tacks and Xails in the Air Passages: Bron- 
 choscopy. Journ. of A. M. A., Feb. 17, 19P2, pp. 40r-4i;9. 
 
 226. Ingals, E. F. Treatment of Foreign Bodies in the Esii|)h- 
 agus. The Laryngoscope, Jan.. 19T2, N'ol. XXII, Xo. 1, p. 47. .Also .\m. 
 Journ. Surgery, Jan., 1912. 
 
 227. Ingals, E. F. Bronchoscopy and Esophagoscopy : The 
 Technic, Utility and Dangers. The Laryngoscope. July, 1909, and .\nn. 
 of Otol., Rhinol. and Laryngol.. March, PH)!). 
 
 22s. Ln'GAls, E. F. Bronchosco]iy for Removal of Foreign I'lodies 
 from the Lungs. N. Y. Med. Journ. and Phila. Med. Journ., Julv S and 
 1.1, 190.V 
 
 229. Jackson, Chev.vluCu. .\ncsthclic .\ttachment for the Bron- 
 choscope. The Laryngoscope, February, PHO. 
 
 2.30. J.\CKsnN, CiiKv.M.iKR. .A Xew Bronchoscope. Laryngoscope, 
 March, I90.S.
 
 BIDLIOC.UAPIIY. 685 
 
 ■2-'!l. jACKSdX. CiiKvALii'K. A Foreign Body Extraclor ( nK-chanic- 
 al spoon). The Laryngoscope, July, IS-'OS. 
 
 'i'.Vi. Jackson. Ciii:\'ALir.K. Drowning oi the Tatienl in llis (. )\\n 
 Secretion. Editorial. The Laryngoscope, Dec. IKlh 
 
 233. Jackson, Chevalier. Foreign Bodies. The Aid of Esoph- 
 agoscopy. Bronchoscopy and Alagnetism in Their Extraction. The 
 Laryngoscope, April, liX).'). 
 
 ■.':M. Jackson, Chkv.\liKR. Endothelioma of the Larynx. Report 
 of a Case. PennsyKania Med. Journ., June, I'.iOT. 
 
 2o~). J.\cks()N, Chkvai.ii;k. Insufflation Anesthesia. Editorial. [ 
 The Laryngoscope, Sept., l!!].'!. 
 
 23(1. Jackson, Ciiev.vliKR. Bronchoscopy and L:npha,ioscnpy. 
 Journ. A. M. A., Sept. 25, 190i), Vol. LITI, pp. 1009-1013. 
 
 237. Jackson, Chi-:\'.\liKr. Statistics of Seventy Cases of (^as- 
 troscopy. .Vmerican Journ. of the Med. Sciences, July, 1908. 
 
 238. Jackson, Cukv.m.ikr. The Dilatation of Bronchial Stric- 
 tures. Journ. of the A. M. A., Sept. 21; 1912. \nl. LIX, pp. n23-112(i. 
 
 239. Jackson, Ciii'VAI.iKR. Gastroscopy. .\rchives Internation- 
 ales de Laryngologie. 
 
 210. J.'\CKSON, CuUv.M.ii'u. \'oluniary Aspiration of a Foreign 
 Body into the Bronclii. Renio\al hy Bronchoscopy. The Laryngoscope. 
 St. Louis, Dec, 1909. 
 
 241. Jackson, Ciii:v.M,ii;k. Esophageal Stenosis F'ollowing the 
 Swallowing of Caustic .\lkalies. Journ. of .\. !\I. A., Nov. 20, 1910, \'ol. 
 L\', pp. 18.57-lSr)8. 
 
 212. Jackson, Ciii;v.m.ikr. Laryngeal. Bronchial and Esophageal 
 Endoscopy. Editinial, Laryngoscoi)e, \'ol. X.XI, X'o. 12, Dec, 1911, 
 p. 1183. 
 
 213. Jackson. Chi-aai.ikk. The Brondioscope as an .\id in Gen- 
 eral Diagnosis. Archives of Diagnosis, Ajiril, 1908. 
 
 2M. Jackson, Cin;vAi.Ti:R. Tracheotomy. The Laryngoscope, 
 Aiirii, Bio!i. 
 
 21'). Jackson, CihA'ai.iku. Position for l-'.ndoscopy. ( IvlildriaH 
 The Laryngoscope, May, 1912. 
 
 2!(;. Jackson, Ciikvami-k. Influenzal Tracheitis. (Editorial) 
 The Laryngoscope, February. 1912. 
 
 2IL J.\CKS()N, CiiKVALiKK. Direct Methods of Examination of the 
 Larynx, Trachea. Bronchi, Esophagus and Stomach. International Clin- 
 ics. \'i)l. IP Twenty-second Series. 
 
 2 IS. J.\CKSoN, Ciiiaai.ii;r. Larvngo^tomy. The Laryng(isco[ie, 
 Sei)l., 1909, 
 
 249. J.\CKS()N, Ciii;\-.\i.ii;u. Tracheohronchoscopy. .\nnais of 
 Surg, for .March, I!iu8.
 
 686 BIBI.IOGRAPHV. 
 
 250. Jackson, Chevai.ikr. Clinical Diagnosis and Operative Pro- 
 cedure in Intralaryngeal Carcinoma, from the Standpoint of the Laryn- 
 gologist. The Laryngoscope, Aug., 1909. 
 
 251. Jackson, Chevalier. Direct Laryngoscopes. The Laryngo- 
 scope, June, 1913. 
 
 252. Jackson, Chevalier. The Larynx in Typhoid Fever. Am. 
 Journ. Med. Sci., Nov., 1905. 
 
 253. Jackson, Chevalier. Primary ^lalignant Disease of the 
 Larynx. The Laryngoscope, August, 190-1:. 
 
 254. Jackson, Ciievalie:r. Thyrotoniy and Laryngectomy for 
 Malignant Disease of the Larynx. Brit. ^led. Journ., Nov. 24, 1906. 
 
 255. Jackson, Chevalier. Thymic Tracheostenosis, Tracheos- 
 copy, Thymectomy, Cure. Journ. of the Amer. Med. Ass'n., May 25, 
 1907, Vol. XLVIII, pp. 1753-1756. 
 
 256. Jackson, Chevalier. Esophagoscopic Removal of Open 
 Safety-Pins by New Method. The Laryngoscope, April, IHIO. 
 
 257. Jackson, Chevalier. The Surgery of the Esophagus, Laryn- 
 gologically considered. The Laryngoscope, Oct., 1909. 
 
 258. Jackson, Chevalier. Anesthesia for Peroral Endoscopy. 
 Proc. Amer. Laryngol. Ass'n., 1912, p. 88. (Interesting discussion). 
 
 259. Jackson, Chevalier. Some Problems of Direct Laryngo- 
 scopy and Bronchoscopy. Am. Acad. Opthal. and Oto-Laryngol., 1912. 
 
 260. Jackson, Chevalier. Laryngeal, Bronchial and Esophageal 
 Endoscopy. The Laryngoscope, Vol. XXII, No. 2, Feb., 1912, p. 130. 
 
 261. Jackson, Chevalier. Bronchoscopic Aid in Thoracotomy, 
 1910. 
 
 262. Jackson, Chevalier. Esophagoscopy and Gastroscopy. The 
 Laryngoscope, St. Louis, Sept., 1911. 
 
 263. Jackson, Chevalier. Decannulation and Extubation after 
 Tracheotomy and Intubation, Respectively. Proc. Am. Laryngol. Soc, 
 1913. (Interesting discussion). 
 
 264. Jackson, Chevalier. Tracheobronchoscopy. Journal of 
 Laryngology, Rhinology and Otology. London, Dec, 1907. 
 
 265. Jackson, Chevalier. Esophagoscopy and Gastroscopy. Ref. 
 Handbook Med. Sci., Vol. III. \Vm. \\ood and Co. 
 
 26(). Jackson, Chev.vlhcr. Technic of Insertion of Intratracheal 
 Insufflation Tubes. Surgery, Gynecology and Obstetrics. Oct., 1913. 
 
 267. Jackson, Chevalier. Bronchoscopy. Ref. Handbook Med. 
 Sci., Vol. 11. Wm. Wood and Co. 
 
 268. J.\CKSON, Chev.vliER. Laryngeal Stenosis from Post-typhoid 
 Perichondritis. Annals of Otology, Rhinology and Laryngology, March, 
 1904.
 
 BIBLIOC.KAPHV. <J87 
 
 369. Jackson, ChevaliKR. Tracheohronclioscopy, Esophagoscopy 
 and Gastroscopy. Text Ixjok. fub. hy The Laryngoscope, St. Louis, 
 1907. 
 
 •.i7i>. Jacksox, Ciucvaliek. Recent Advances in Endoscopy of the 
 Larynx, Trachea, Bronchi, Esophagus and Stomach. (Report to the In- 
 ternational IMedical Congress. London. 11113, Section XVl. Also pub- 
 lished in The Laryngoscope, July, 1!>1;3. 
 
 371. Jackson, Chevalier. Obstructions in the Trachea and llron- 
 chi. Musscr-Kelly Hand book of Treatment. Saunders and Co., Phila- 
 delphia. 
 
 273. Jaxewav. H. H. Gastroscopy. Journal Am. ]\ied. Ass'n., 
 Oct. 11, 1913. 
 
 273. Jankway, 11. H. and Green, N. W. Esophagoscopy and 
 Gastroscopy. Surg., Gyn. and Obst., Sept., 1911, p. 245. 
 
 274. JERVEY, J. W. Nail Occluding Third lironchial Ramus; Up- 
 per Bronchoscopy Recovery. Southern Med. Journ., Vol. VL No. 3, 
 March, 1913, p. 191-193. 
 
 275. Johnston, R. H. Esophagoscopy in the Removal of Foreign 
 Bodies. N. Y. Med. Jour., Sept. 4, 1909. 
 
 27(5. Johnston, R. H. E.xtension and Flexion in Direct Laryn- 
 gostomy. A Comparative Study. Ann. of Otol., Rhinol. and Laryngol., 
 March, 1910. 
 
 277. Johnston, R. U. Straight Method of Direct Laryngoscopy. 
 The Laryngoscope, Dec, 1910. 
 
 27S. Johnston, R. H. Direct Laryngoscopy in the Removal of 
 Laryngeal Tumors. The Laryngoscope, Vol. XXI I, Xo. 10, Oct., 191 2, 
 p. 1214. 
 
 279. Johnston, R. H. Esophagoscopy. Laryngoscope, Vol. XXI. 
 Xo. 12, Dec, 1911, p. nr,a. 
 
 2.S0. Johnston, K. IL Some Esophageal Cases. Md. .Med. Jour.. 
 Feb., 1909. 
 
 281. Johnston, R. H. Some Original Endoscopic Methods. 
 Laryngoscope, May, 1913, XXITI, (i07. 
 
 282. JoHN.sToN, R. 11. Straight Direct T^aryngoscopy and Esoph- 
 agoscopy. Am. Acad. ' 'phllial. and Oto-LaryngoL, 1912. 
 
 283. Johnston, R. 11. The Removal of I'oreign l'>odies from the 
 I'pper End of the Esophagus. .\m. .Acad. Ophthal. and Oto-Laryngol.. 
 1912. 
 
 284. Johnston, R. II. Direct Laryngoscopy in Diagnosis and 
 Treatment of Rapillomata of the Larynx. The Laryngo.scope, Xov., 1909. 
 
 2S."i. Johnston, R. II. Removal of Laryngeal Tumors in the Left 
 Lateral Position. The Laryngoscope, May, 1909.
 
 688 niriLiOGRAPHY. 
 
 •<;S(). JoHXSTON, R. H. Direct Laryngoscopy. Cincinnati Lancet- 
 Clinic, Sept. 18, 1909. (An interesting series of cases reported in this 
 article). 
 
 287. Janewav, Hknrv. Intratracheal Anesthesia from the Stand- 
 point of the Nose, Throat and ( )ral Surgeon. The Laryngoscope, Nov., 
 1913. 
 
 288. Jaxeway. H. H. and Green, X. \\'. Cancer of the Esoph- 
 agus and Cardia. Ann. of Surg.. July, 1910. 
 
 29fi. Kahler. Otto. Scabbard Trachea and Pulmonary Emphy- 
 sem.a. I'roc. Stuttgart Laryngological Society, May, 1913. 
 
 29T. Kahler, Otto. Chirurgische Rehandlung der Kehlkoptub- 
 erculose. Monats. f. Ohrenheilkunde 47 Jahrgang, x heft. 
 
 298. Kahi.er, Otto. Esophagoscopy and Bronchoscopy. I'ub. by 
 Montz Lerles. A'ienna, 1909. 
 
 299. Kahler, Otto, bronchoscopy and Esophagoscopy. Laryn- 
 goscope, Sept., 1911. 
 
 300. K.mh.er. Otto. Diverticulum of the Tracheo-Bronchial Tree, 
 Monatschr. f. Ohrenheilk. und Laryngo-RhinoL, Heft 1, 1911. 
 
 301. K.-\hler, Otto. Zur Bronchoskopie bei Fremkorpern. Mon- 
 atschr. f. Ohrenh. u. Laryngo-RhinoL, Heft 2, 1909. 
 
 302. K.xhler, Otto. Bronchoscopy and Esophagoscopy: Their In- 
 dications and Contraindication. Arch. f. Laryn.. \'ol. XX\', Xo. 2. l-'ll. 
 p. 371. 
 
 303. Kelly, A. Bkowx. Some Experiences in the Direct Exam- 
 ination of the Larynx, Trachea and Esophagus. Brit. Isled. Journ.. Sept. 
 2(S, 1908, p. 89fi. 
 
 301. Kelly, A. Browx. Perforation of Esophagus due to Ulcera- 
 tion T'roduced by Foreign Bodies. Proc. Royal Soc. Med., A'ol. A', Xo. 
 7, May, 1912. 
 
 30.5. Kelly', a. Brown. Stenoses at the Lower End of the Esoph- 
 agus, with Special Reference to those of Spastic Origin. Brit. Med. 
 Jour., Oct. 19, 1912. 
 
 300. Killian, Gustav. Laryngoscopy. Berl. Klin. W'och.. Xo 
 13, March 2.5, 1912, p, 581, 
 
 307. KiLLTAX, Gustav. Short Hints for Examining the Esophagus, 
 Trachea and Bronchi by Direct Methods. Printed as MS. 
 
 308. Kn.ii\x, Gt'ST.w. Suspension LarA'ugoscopy. .\rcliiv. f. 
 Laryngol. und Rhin., Bd. XX\"I, Xo. 2, p. 278. 
 
 309. KiLLTAX. F. The History of Bronchoscopy and Esophagos- 
 copy. Deutsche :\Ied. Woch.. 1911. Xo. 35, Aug. 31, p. 1585. 
 
 310. KiLLTAX, G. Tracheohronchoscony in its Diagnostic and 
 Therapeutical Aspects. The Laryngoscope, St. Louis, Dec, 190(;.
 
 BIP-LTOGRAIMIV. (>89 
 
 :!11. KiLLiAN, GuSTAv. l^ic Dircclen Methoden in den Jahien, 
 I'M 1 und liU'i. Proc. Internal. Med. Congress, ISHo. 
 
 Wi. KiLLiAX, GusTAv. Improved Technic for Laryngoscopy. Ber- 
 liner Klinische Wochenschrift, March 2."), XLIX, No. 13, pp. 581-1538. 
 
 .■?1.'!. KoscHiKR, H. Operative Treatment of Carcinoma of tlie 
 I-arynx. \\'ien. Klin. W'och.. \'ol. XXII, No. 27. 
 
 M14. Krp.u, Ixo. (Japan). Stenosis of the Trachea and Esoph- 
 agus due to Pressure from an Abscess of a Thoracic \'ertebra, Diag- 
 nosed by Means of Tracheoscopy and Esophagoscopy ; Operation; Im- 
 provement. Arch. f. Earyng.. \'ol. XX\', X'o. 3, 1911, p. ."iOH. 
 
 31."). KuBo, Ino. The Present Status of the Direct Method in 
 Japan. Semon's Internat. Centralblatt f. Earyngol.. Rhin.. etc.. No. 10. 
 1013. 
 
 31(1. KuH.x, F. .\ND MeltzER, S. J. Intra-trachcal Insufflation and 
 Peroral Intubation P)erl. Klin., W'chnschr., Se])t. IK, 1910. 
 
 317. Kyle, D. Uraden. Diseases of the Nose and Throat. \V. B. 
 Saunders. 
 
 31 s. Kvi.E, Joiix J. Direct Laryngoscopy and Tracheobronchos- 
 copy. Journ. of the Indiana State Med. -Ass'n., Feb. 1"), IDiKS. 
 
 319. KvLE, D. Brauex. Removal of a Toothjilate that had Re- 
 mained in the Esophagus Seventeen Years. Transactions Am. Laryngol. 
 Soc, I!113. .Also I'roc. Internat. Med. Congress, Section XV, London, 
 1!I13. 
 
 320. Kvi.i;, D. ISraden. Surgical Treatment of Tubercular Lesions 
 of the I'pper Respiratory Tract. Proc. Sixth International Congress on 
 Tulierculosis. 
 
 321. KvEE, D. Braden. Nose and Throat (Text book ). Saunders 
 Co., Philadelphia. 
 
 322. KxEEDEEu, 0. C. Tracheotomy. I'gh. Med. JDurn., Jan., 
 1014. 
 
 323. KiusTEix, A. .\utoscopy. Ilerlin Klin. Woch., No. 22, 1895. 
 32-1. Ktr.syeix. .•\. .\utoscopy. (Monograph). Coblentz, 1906. 
 325. Koii .\Ni) Wads.vck. Echinococcus of the Left Lung. Ilerlin 
 
 Klin. Woch., p. 1097. Xo. 33, 1900. 
 
 3v!.S. Le\'i', R(ii;i;k'i'. Tuberculosis of the Mouth. ( Excellent col- 
 ored illustrations.) The Laryngoscope, Dec, 19o7. 
 
 329. LiEHAfET, G. A. M. Chmnic Inllamnialory Stenoses of the 
 Esophagus, 'i'hesis 191. Faculty of .Medicine. L'niversity of Paris. 
 1913. 
 
 330. Lai'.iuke. Esophagoscopy for Foreign liodies. Arch. In- 
 tern, de I.aryng.. Jan.-I'eb.. 1912, [). 83.
 
 GOO BIBLIOGRAPHY. 
 
 331. Lack. H. L: Delsaux, \'.. and Delavax, D. ]!. Treatment 
 of Cicatricial vStenosi.s of the Larynx. Brit. Med. Jour., Oct. l(i, 1!>0!I. 
 
 332. Landon, L. H. Practicability of the Meltzer-Auer Method of 
 Continuous Intra-tracheal InsuiYlation. L'niversity of Pa. Med. Bull, 
 July-August, I'JIO. 
 
 333. Lange, S. The Roentgen Examination of the Esophagus. N. 
 y. Med. Jour., Jan. 23, IDOO. 
 
 334. Lange, S. Early Recognition of Esophageal Stricture. Med. 
 Record, Jan. ](), 1909. 
 
 335. L.\rge, S. H. Pathological Lesions and Trachea. Lantern 
 Slides. Am. Acad. Ophthal. and C)to-Lar}-ngol., 1912. 
 
 33G. Large, S. Some of My Mishaps in Seventy-five cases of 
 Tracheobronchoscopy and Esophagoscopy. The Laryngoscope, Nov., 
 1910. 
 
 337. Large, S. H. Foreign Body in Right Bronchus. Cleveland 
 Med. Jour., Nov., 1909. 
 
 338. Laurent, F. \'. Respiration for Tone-Production. The 
 Lar)'ngoscope, Dec, 191ii. 
 
 339., Lazarraga. Complete Removal of Larynx Under Local 
 .■\neslhesia. Its advantages. Arch. Liternat. de Laryngol.. d'Otol. et de 
 Rhinol., Xov.-Dec, 1910. 
 
 340. Leavy, Chas. a. Chronic Stenosis of Larynx and Trachea. 
 Report of Case. The Laryngoscope, 1913. 
 
 341. Lederman, M. D. Edema of the Larynx Following an In- 
 fection of the Lower Pharynx. The Laryngoscope, May, 1909. 
 
 342. Lerche, Wm. a Contribution to the Surgery of the Esoph- 
 agus. Surg. Gynecology and Obstetrics. Oct., 1910, pages 34.")-3()l. 
 
 343. Lewisohn, Richard. A Xew Principle in Esophagoscopy and 
 Gastroscopy. Annals of Surgery, A'ol. LXTI, Xo. 1, Jan., 1913, p. 28. 
 
 3-14. Lewisohn, Richard. A Xew Esophagoscope. Journ. Amer. 
 Med. Ass'n., Nov., 1911, p. 1081. 
 
 345. Liijenthal, H. First Case of Thoracotomy in a Human Be- 
 ing under Anesthesia by Intra-tracheal Insufflation. Ann of Surg., July, 
 1910 
 
 34G. LocKARD, L. B. .Amputation of Epiglottis in Laryngeal Tu- 
 berculosis. Denver Med. Times and Utah Med. Jour., Oct., 1910. 
 
 34T. London, Jui.us. A .\'cw Gastro-Esophagoscope. Medical 
 Record, \'ol. LXXXII, Xo. 25, Dec. 21, 1912, p. 1125. 
 
 348. LoEB, Hanai' W. Fibropapilloma of the Larynx. .\nn. Otol.. 
 Rhinol. and Laryngol., Xov., 1902. 
 
 349. Lynah, Hexrv L. Diphtheritic Stenosis of the Larynx. 
 The Laryngoscope, Dec, 1913.
 
 EIliUIOCKAPIIY. (591 
 
 350. Lv.NCii, R. C. ^Magnetic Extraction of a Foreign I'.ody from 
 the Dronchus. Proc. Amer. Acad. Ophthalmol, and Oto-Laryngol., l!ii:5. 
 
 351. I-KviNGKR. r^lultiple Osteomata of the Trachea Clinically 
 Diagnosticated hy Means of Direct Tracheoscopy. Muench. med. 
 Wchnschr., .\'ov. L"). in in. 
 
 352. LiTciU'iiiLn, LawkKnck. .\hnse of Xormal Salt Solution. 
 Journ. A. AI. A., July 25. 1014. 
 
 35C. .Mel'i'zKr. Intratracheal Insufflation Anesthesia. Bulletins 
 Rockefeller Institute, New York City, liUO, 1911, 1913. 
 
 357. M.\CMi-:, JoHX S. Removal of a Stick-Pin from the Second 
 Bifurcation by Direct Bronchoscopy under Local -Anesthesia. Journal 
 Lancet, August 15, 1913. 
 
 358. M.\cDo.N-.\i,i), W. .\. Congenital Membrane Between \ ocal 
 Cords. Can. Jour, of Med. and Surg., Dec, 1909. 
 
 359. M.\Kri:x, (i. lii'DsoN. Respiratory and \'ocal Symptoms in 
 Papillomata of the Larynx. .Ann. of Otol., Rhinol and Laryngoi., Sept., 
 1910. 
 
 .'Kio. M.\KU!vN, G. Hudson.. Removal of an Open Safety-Pin from 
 the Trachea by L^ppcr Pironchoscopy. Journ. of the Amer. .Med. Ass'n., 
 July 22, 19n, \nl. L\ll. p. 2S(i. 
 
 3(;i. .M.\.\.\, M. .Atlas of Killian's Tracheobronchoscopy. (Ex- 
 cellent colored jilates of pathological specimens of trachea, mediastinal 
 tumors, etc.). Pub. b\- Curl Kabitzsch. W'iirzliurg. (I-ehrbuch der 
 P)ronchoskf)i)ic, by same author and ]iublislier just published as we go to 
 press, is an excellent jiractical manual i. 
 
 3f)2. M.\NX, R. H. T. Removal of a Grain of C'orn from the I'.n- 
 trance of the Left ISronchus of a Child I'our 'N'ears ' )ld. Jour, .\rkans. 
 Med. Soc. .\pril, 1910. 
 
 3(i3. M.'WX, R. H. T. Foreign bodies in the Air Passages and the 
 Esophagus. Jour. Kansas Med. Soc, Vol. XIII, No. 4, April. 1913, p. 
 155. 
 
 3(;i. Mar.sciiik, H. and Vogkl, R. Fremkorpcr in den oberen 
 Lull und Speisenwegen mit besonderer Beriicksichtigung der Esopha- 
 gotomie. W'ien Klin. Wchnschr.. ( )cl. 1 I, 19<i9. 
 
 3()5. M.\KsciiiK, J I. Larynxcarcinom bei Jugendlichen Personen. 
 Monatschr. f. ( )hrenh. u. Laryngo-Rhinol., Ileft 9, 1!i()9. 
 
 3()(i. Masox, \'. R. AXn Ixr.tjs, fl. J. .\cute Iviema i>f the Larynx 
 Following luherizalion for l'"orcei)s l)eli\ery. Reiiort of a Case. Boston 
 Med. and Surg. Jour.. June 2, 19 In. 
 
 3(u. Masski. Complete Review of the Clinical Laryngological 
 Work for 19ii9. .Monograph .\ai)les. I'.Mn.
 
 CSI3 BIBLIOGRAPHY. 
 
 308. AIassei, F. Direct and Indirect Laryngoscopy. 2ilonat. t. 
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 ;i()!). Matthews. The Relation of Xasal Conditions to Asthma 
 Journ. Ainer. Med. Ass'n., Oct. 12, 1912. 
 
 ;mO. M.-wer, Emu,. Treatment of Cicatricial Stenosis of the 
 Larynx. The Laryngoscope, Jan., 1912. 
 
 371. Mayeu, E., and YankauER, J. Further Bronchoscopic Ob- 
 servations. Zeitschr. f. Laryng., \'ol. I\', Xo. 3. 1911, p. 395. 
 
 372. Mayer, E. Stenosis of the Larynx Cured by Intubation. Med. 
 Record, Dec. 25, 1909. 
 
 373. Mayer, E. Esophageal Diverticula. Proceedings Am. Laryn- 
 gological Association, 19ln. 
 
 371. Mayer, E. Further Report of a Case of Tracheal Scleroma. 
 Am. Jour, of Med. Sci.. Feb., 1909. 
 
 375. M.wo, C. H. Diagnosis and Surgical Treatment of Eso- 
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 37(1. McKenzie, Dan. The Laryngectomy. Journ. Laryngol. 
 Khiiiol., ( )ct., 1SI13. 
 
 377. McKiNXEY, R. Esophagoscopy in the Removal of Foreign 
 Bodies from the Esophagus. Laryngoscope, Oct., 1912. 
 
 378. McReynolds, J. O. Mastoiditis Complicated by L'lceration 
 and Rupture of the Esophagus. Texas State Jour, of Med., Oct., 190(5. 
 
 379. MeetzER, S. I. Method of Respiration by Intratracheal In- 
 suft'lation ; its Scientific Principle and its Practical Availability in Medi- 
 cine and Surgery. Med. Record, March l!i, 191(1, and Berl. Klin. 
 \\ clinschr., March 21, 1910. (Excellent resume bv same author in Rerl. 
 Klin. W'och., Xo. 15 and Ki, 1914). 
 
 380. Miller, Clieto.n M. Chronic Xasal Diphtheria. \'irginia 
 Med. Semi-Monthly . .\i)ril 12. lit 12. 
 
 381. Miller, ;\Iorkl^ B. Perforation of the Ileum In* Foreign 
 Bodies. Annals of Surgery, .\nv.. 1913, p. 707. 
 
 382. MiLLSP.AVGii, W. I'. Interesting Esophageal Cases. The 
 Laryngoscope, Sept., I!tl3. 
 
 383. ]\IiLLSPACGii, W. P. Esophagoscopy for Removal of Foreign 
 Bodies. Southern Cal. Practitioner, \ol. XX\TL Xo. (i, June, 1912, p. 
 2fi5. Also April, 1912. 
 
 384. Mermod, (Lausanne). Hemorrhagies dans les Interxentions 
 Endo-laryngees. Archives Internationales. 1913. 
 
 385. Mermod (Lausanne). Propulsion of the Tongue in Direct 
 Laryngoscopy, -\rchi\es Intcrnat. de Laryngol., d'Otol. et dc Rhinol., 
 1912.
 
 BIBLIOGRAPIIV. (J9;5 
 
 386. MONSON, S. H. l''()rcign Body in the Larynx. Clexeland 
 Med. jour., jinif, IVHO. 
 
 ;^sT. MiMiKiiK.M), RouKKT L. Foreign Body in the Trachea Re- 
 moved by Mean.s of the Bronchoscope. Long Island Med. Journ., \'ol. 
 \'L Xo. :. July. 1!M--', p. -ir,]. 
 
 .■)8S. .Miism.K, n. P. Three E.sophageal Cases. The Laryngoscope, 
 Oct., BH)9. 
 
 :is'.». .\hi.siii:R, IL 1'. Direct Intuhaticm of the Laryn.x. The 
 Laryngoscope. Oct., liHiii. 
 
 :iliii. MosiucR, H. 1'. The Direct Examination of the Larynx and 
 of the L'p])er I'.nd of the Esophagus by tiie Lateral Route. Boston ^L>-'d. 
 and v^urg. journ., \'ol. CLN'ITT, No. (!, pp. 1S!)-1!)L Feb. G, 1908. 
 
 ;!91. .M()siii:u, li. p. A Tube for Closing and Removing an Open 
 Safetj--Pin. The Laryngoscope, Oct., 191 L 
 
 ;i92. .McjURK, L. T. De I'examen Gastrosco])iiiue. La I'resse Medi- 
 cale, February :5, JIM.'. 
 
 .S9;L Munch, F. 'J'echnic of IJirect N'isual Ins])ection of Upper 
 .Air Passages, Esophagus and Stomach. Presse Med., March ;31, 1909. 
 
 •'!91. MfNCii, F. Bronchoscopie et Esophagoscopie. Rev. hebd. 
 de Laryngol., d'C Hoi. et de Rhinol., Sept. 11, 1909. 
 
 :19."). MiRi'iiv, J. Direct Examination of the Larynx, Trachea, 
 Bronchi and Esophagus, .\ustralian Aled. Join-., ( )ct.. 1910. 
 
 .'!9i;. Murphy, J. W. Bronchoscopy, with the Report of Two 
 Cases. Lancet-Clinic, vSept. :i(i, 1911, p. ;);3S. 
 
 o9T. MuKiMiv, J. W. Tracheobronchoscopy, Esophagoscopv and 
 Gastroscojiy. Cincinnati Lancet Clinic, July IL 1908. 
 
 .'598. Mi'RPiiv, J. W. Removal of Foreign I'odies from the Tra- 
 chea and Eso[)hagus. Ky. Med. Jour., ()ct. 1, 1909. 
 
 :i99. Mvi-R, Jessk S. Cardiospasm with Dilatation of the Esoph- 
 agus. Journ. of tile Amer. Med. Ass'n., ( )ct. 'i'-K PMo, \ul. l.W pp. 
 l.-|| LL-..-.0. 
 
 1'"'. .\hi;R, J. S. Cardiosjiasni with Dil.atalicjn of the Esophagus. 
 Jour. A. M. A., Oct. 29, l9lo. 
 
 loi. Mrsso.x', Emm.\ E. Endoscopic Treatment nf Lronchiectasis. 
 Peim'a. Med. Journ.. Jan.. 191-1. 
 
 lovJ. McKinm:v, R. Comparison ni the Technic of I'.roncho- 
 l'.sophagosco])y with Jackson's and Uriinings' .Methods. ( h'avors Briin- 
 ings). 
 
 io:!. .\|o^iii:r. 11. P. Some ( )bservations on Eso])hageal Cases 
 The Laryngoscope. June, 1909. 
 
 loi. .Mi;iiNKKT. ,\natnmy of the I-isoi'hagus. .\rchiv. fiir Klin. 
 Chir., P.d. •.':, p. 7(;.
 
 694 BIBLIOGRAPHY. 
 
 405. MoSHEE, H. P. Esophagoscope in Esophageal Surgery. Bos- 
 ton Med. and Surg. Journ., Sept. 14, 1911. 
 
 4()(). MouRiCT, J. Laryngo-Tracheo-Bronchoscopy and Esophagos- 
 copy in the Sitting Position. Bulletin !^oc. FVancaise d'Oto-rhino-laryn- 
 gologie, 1913. 
 
 407. Mermod, (Lausanne). Traitement de la Tuberculose par le 
 Galvano-cautere. Archi\'es Internationales ( Chauveau ) ( )ct. to Dec. 
 19(M. 
 
 408. Mayer, Emu,. Report of a Case of Tracheal Tumor. Pro- 
 ceedings Am. Med. Assn., Sect. Laryngol. and Otol., 19 Ti^, p. 183. 
 
 409. MacklESTON. Osteomata of the Trachea. The Laryngo- 
 scope, Dec, 1909. 
 
 410. McKenzie, Dan. Removal of a Foreign Body From the 
 Larynx. Lancet, July 14, 1914. 
 
 411. Neumann, Friedr. Endolaryngeal and Endobronchial Oper- 
 ations. IMonatschr. f. Ohrenheilk., Oct., 1911, p. 1113. 
 
 412. Norris, R. T. Pin Removed from Ascending Division of 
 Left Bronchus with Aid of Fluoroscopic Screen. Surg., Gynecol, and Ob- 
 stetrics, May, 1910. 
 
 413. NowoTNY. Uber die Bronschoskopie als Heilmethode bei 
 Bronchialstenose. Przeglad Lekarski, No. 24 and 25, 1909. 
 
 419. O'Dwyer. Chronic Stenosis of the Larynx Treated by a New 
 Method. N. Y. Med. Rec June 5, 188G. 
 
 420. O'Dwyer. Intubation for Chronic Stenosis of the Larynx. 
 N. Y. Med. Journ., March 10. 1888. 
 
 421. O'Reilly, Charles A. Demonstration of the Kahler Bron- 
 choscope. The Laryngoscope, Aug., Sept., 1913. (Interesting discussion 
 on Instruments.) 
 
 42T. Packard, F. R. History of a Case of Recurrent Papilloma 
 of the Larynx, Extending over Thirty Years. During which two Thyrot- 
 omies were Performed. Ann. of Otol., Rhinol. and Laryngol.. Sept.. 
 1910. 
 
 428. Parker, Charles. Surgery of the Thymus Gland. Thy- 
 mectomy. Report of Fifty Operated Cases. Amer. Jour, of Diseases of 
 Children. Feb., 1913, Vol. 5, pp. 89-122. 
 
 429. Patterson, Ellen J. Hyoid Bone Elevation in General An- 
 esthesia. Annals of Surgery, Nov., 1913. 
 
 430. Petit de la Villeon. Foreign Body in Esophagus. Fatal 
 Hemorrhage Through Perforation of Aorta. Gaz. hebd. des Sci. med., 
 Oct 23, 1910. 
 
 431. PfahleR, G. Diagnosis of Carcinoma of the Esophagus by 
 the Roentgen Ravs. Arch, of Diag., Tan.. 1909.
 
 EIRLIOC.KAPIIV. 695 
 
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 Hen'RICH : Contribution to the Clinic of Direct .Methods of Examination. 
 
 .Muenchn. Mcdicin. U'ochcnschr., Xo. 48. 1913. 
 IIi-:vM.\,\.\ : Transacticins of ilu' .Society of Charite-physicians, \'ol. 18, 
 
 1912. 
 Hoelscher: Experiences with Suspension-laryngoscopy. 
 
 Society of Charite Physicians. Meeting of May 2, 1912. Berliner 
 Klin. U'ochcnschr., Xo. 27, \'ol. 4!), July 1. 1912. p. 12!M-95.
 
 704 BIBLIOGRAPHY. 
 
 Hoei.scher: About Clinical Experiences with Kiilian's Suspension- 
 laryngoscopy. 
 Med. Corresp. Bl. d. U'licrtcinherg. acrztl. Laiidrsvcrcins. No. 
 24, 1912. Semon's Intcniat. Centralbl. f. Larynyol., Rhiuol. it. 
 verzv. IFisscnsch, \o\. XXXIII, Sept., 1912, No. 9, p. 483. 
 Hoelscher: 
 
 Transactions of the Society of German Laryngologists, 191:!, p. 144. 
 HOPMANN : 
 
 Mucnchn. Med. Woehcnselir., 191;^,. p. 1742. 
 HowARTii, W. : A Hook-spatula for Suspension-laryngoscopy. 
 
 Lancet, July 19, 1913. Semon's Internal. Centralbl. f. Laryngol., 
 Rhhiol. n. veriv. IVisscnseh, \'o\. XXIX, Nov. 1913, No. 11, p. 
 550. 
 IglauER, Samuel : Foreign Bodies in Larynx and Trachea Removed 
 by the Aid of Suspension-laryngoscope. 
 The Laryngoseope, June. 1913. Semon's Internal. Centralbl. f. 
 Laryngol., Rliinol. u. verie. ll'issenseli. Dec, 1913. \'ol XXIX, 
 No. 12, p. GOl. 
 Kaempeer. Louis G. : Suspension-laryngoscopy. 
 
 A'eiv York Medical Journal, Jan. 4, 1913. Semon's Internat. Cen- 
 trbl. f. Laryngol., Rlunol. u. verxe. U'issenscli. \'ol. XXIX, June 
 1913, No. fi, p. 285. 
 Kahler, Otto: Tlic Chirurgical Intra and Extra Laryngeal Treatment 
 of Laryngeal Tuberculosis. 
 Ref. Delivered at the H~nh Meeting of Xaturalists in \'ienna 
 (p. 12T5). Monatsselir. f. Ohrenheitkinide n. Laryniio-Rliinol- 
 ogie,\'n\. XIA'II, 19]:;, pp. Ti(;!)-l2s:i. 
 Katzenstein : 
 
 Transactions of the Society of German Laryngologists, 1913, p. 143. 
 KiLLiA^: Suspension-laryngoscopy. A Modification of the Direct 
 iMethod. 
 Transactions of the III International Laryngo-khinological Con- 
 gress, Berlin, .August :iii-Septeml)er 2, liMl, ji. 112, Part II: 
 Transactions. 
 
 Killian: On Susy)ension-laryngoscoi>y. 
 
 Berlin. Klin. W ochenschr., Xo. 13, 1912. Semon's Internat- Cen- 
 trbl. f. Laryngol., Rhinol. n. z'erw. ll'issenseli. \ ol. XXIX, Jan- 
 uary, 1913, No. ], p. 5. 
 KiLLiAX : On Suspension-laryngoscopy. 
 
 Society of Charito Physicians, Meeting of May 2, 1912. Berliner 
 Klin, ll'oeliensclir.. Xo. 27, \'ol. 19. July 1, l!n2, p. 1293-94.
 
 Bir.I.KIGRAl'llY. 705 
 
 KiLLiAN, GusTAv: Suspension-laiviigoscopy. 
 
 Rc'iniiit fnim the .Ircli. of Larymju!. and RliinoL, \'ol. ■>ti, Xo. "-i, Uer- 
 liii. 1912. 
 Kii.i.iAx; ( )n Suspension -larynsjoscopy. 
 
 Berlin. Klin. U'uchdisclir., No. 27, p. 1293, 1912. Semon's Internal. 
 Ccntrbl. f. LarynyoL, Rhinol. u. vcriv. Wisscnscli., \'o\. XXIX, 
 January, 1913, No. 1, p. ."). 
 KiLLiAN : The Suspension-hook in its Newest Form. 
 
 Transactions of the Society of German Laryngol., 1913, p. 25. 
 KiLLiAN : Demonstrations of Suspension-laryngoscopy. 
 
 Transactions of the Internat. Med. Congress, London, 1913. 
 
 KlI.LIAN : 
 
 Naturahsts' Meeting, X'icnna, 1913, Laryngol. Section. 
 Kii.Li.\N : On Suspension-laryngoscopy. 
 
 1913, Berliner Klin. ll'ochcn.<;chr. 
 Klkstadt : 
 
 Berlin. Klin, ll'ochenschr., 1913, No. 3, p. 133. 
 Lautf.nschlaeger : 
 
 Berlin. Klin. W'ochcnschr., 1913, p. 4-18. 
 Mann : 
 
 Transactions of the Society of German Laryngologists, 1913, p. 
 144. 
 M.\^'i:k, E. : Removal of a Carcinoma of the Epiglottis by Suspension- 
 laryngoscopy. 
 
 Arch. f. Laryngol, p. r)92, \'o]. 27, No. 3. 
 Poi,i..\tsciii-:k : Direct C)perations upon the I.ar\n.\. 
 
 Orvosi hctihif'.. No. 49, 1912. 
 vSkiki'Krt : The Killian Suspensioti-Iaryngoscop}-. 
 
 Zeitschr. /'. Laryngoloyie ii. Rliinolof/ie, VL H. 4, 1913. 
 SiEGEL: Twilight Sleep in Obstetrics with Sdlulions of Skoinilaniine. 
 
 Muenclm. Medic. JVoclicnsclir., 1913. 
 SiMDi.i'Ki : Laryngeal Scleroma Treated by Suspension-laryngoscopy. 
 Monatschr. f. Ohrcniieilk. ti. Laryngo-Rhinologie, Vol. XLVH, 
 No. 7, p. 9S9. 
 Sti-i.nkr : C)n Suspension-laryngu.scopy. 
 
 I'rager Medicin. IVochenschr., 1913, No. 28. 
 Storatii : 
 
 Muenclm. Mcdiz. H'oclicn.schr., 1913, p. 325. 
 Straitb: On Decomposition and Conservation of Skoiiol.uiiine Sdluliuns. 
 
 Muenclm. Med. IVochenschr., 1913, No. 41. 
 W'OT.EF, J. H.; Demonstration (if an Apparatus for Suspension-larvngos- 
 
 I'CIJIV. 
 
 Laryngological Society of Berlin, Meeting of April 19, I91J. Berlin. 
 Klin Jl'ochrnschr., June 10, 1912. No. 24, Vol. 19, p. ll.M.
 
 Description of Colored Plates. 
 
 PLATE I. 
 
 LARYNGEAL AND TRACHKAL STENOSES. 
 
 1. Direct view. Sitting position. Male, aged 14 years. Post- 
 diphtheritic cicatricial stenosis cured by endoscopic evisceration. (See 
 Fig. 5.) Known to be well two years after decannnlation. 
 
 2. Direct view. Sitting position. Male, aged 18 years. Post- 
 typhoid cicatricial stenosis, ^lucosa was very cyanotic because cannula 
 was removed for laryngoscopy and bronchoscopy. Cured by laryn- 
 gostomy (See Fig. G). Still well four years after decannnlation and 
 plastic closure. 
 
 3. Direct view. Sitting position. Male, aged 37 years. Post- 
 typhoid infiltrative stenosis. Left arytenoid destroyed by necrosis. Cured 
 by laryngostomy. Failure to form adventitious band (Fig. 7) because 
 of lack of arytenoid activity. 
 
 4. Direct view. Recumbent position. Male, aged 40 years. Post- 
 typhoid cicatricial stenosis. Cured of stenosis by endoscopic eviscera- 
 tion with sliding-punch forceps. Anterior commissure twice afterward 
 cleared of cicatricial tissue as in other case shown in Fig. l-"). Ultimate 
 result shown in Fig. S. 
 
 •5. Same patient as Fig. 1. Sketch made two years after decan- 
 nnlation and plastic. 
 
 G. Same patient as Fig. 3. Sketch made four years after decan- 
 nnlation and plastic. 
 
 7. Same patient as Fig. 3. Sketch made three years after decan- 
 nnlation and plastic. 
 
 8. Same i>atient as Fig. 4. Sketch made one year after decan- 
 nnlation, fourteen months after clearing of the anterior commissure to 
 form adventitious cords.
 
 (g)(i)(|) 
 
 PLATE I. 
 
 Direct laryngoscopic views. Photoj^'raphic reproduction of oil color- 
 drawintjs from life by the author. For description, see previous pages.
 
 QO(S>©® 
 
 PLATE II. 
 
 Direct and indirect laryngeal views. Photographic reproduction of oil 
 color-drawings from life by the author. For description, see previous pages.
 
 DESCRIPTION OF COLOR PI.ATliS. 707 
 
 9. Direct \ic\v. Kccumheiit. Female, aged 1(1 years. W eb post- 
 dii)htlieritic (?) or congenital (?). "Rough voice" since birth Imt 
 larynx never examined until stenoscd after diphtheria. W'eh removed 
 and larynx eviscerated with punch forceps. Recurrence of stenosis (not 
 of web). Cure by laryngostomy. This view also illustrates the true 
 depth of the larynx which is often overlooked because of the misleading 
 flatness of laryngeal illustrations. 
 
 10. Direct laryngoscopic view. Child, aged 22 months. Post- 
 dijjhtheritic hypertrophic subglottic stenosis. Cured by galvano-cauteri- 
 zation. 
 
 11. Direct laryngoscopic view. Child, aged three years. Post- 
 di[)htheritic hypertrophic supraglottic stenosis. Forceps excision, 
 b'-xtiibation one month later. Still well four years later. 
 
 12. r»ronchoscopic view of post-tracheotomic stenosis foHowing' a 
 "plastic flap" tracheotomy done for acute edema. Male, aged 17 years. 
 (Not treated because of advanced nephritis). 
 
 1.3. Direct laryngoscopic view. Anterolateral thymic compression 
 stenosis in a child of IS months. Cured by thymopcxy. Seen six months 
 later. Still well. 
 
 II. Indirect laryngoscoi)ic ( mirror i view. I.aryngostomv ruliber 
 tube in position in treatment of post-typhoid stenosis. W'nnian, aged 
 30 years. 
 
 15. Direct \iew. Post-typhoid stenosis after cure b\' laryngostomy. 
 Male, aged 30 years. Dotted line shows place of excision for clearing 
 out the anterior commissure to restore the voice. 
 
 in. Endosco]iic \icw of post-tracheolomic tracheal stenosis from 
 badly placed incision and chondrial necrosis, in a child of three years. 
 Tracheotomj- originally done for influenzal tracheitis. Cured by tracheos- 
 tomy. 
 
 PL.M'K II. 
 
 DIRKCT \.\I> INl)IU::ci' I..\ltVi\"C.K.\l. VIICWS. 
 
 Fig. I. Ki)igloltis of child as seen b\- dircci laryngoscopy in the 
 recumbent i>osition. 2. .Normal larynx spasmodically closed as is usual 
 on first exposure without anesthesia. 3. Same on inspiration. I. Supra- 
 glottic papillomata as seen on direct laryngosco|)y in a child of two 
 years. 5. Cyst of the lai"ynx in a child of four years, seen on direct 
 laryngoscopy without anesthesia, (i. Indirect \icw of larynx eight weeks 
 after tbyrcjtoniy for cancer of the right cord in a man of tift\- years. 
 7. Same after two vcars. .\n a<l\cntitious liand indistinguish.-dile troni
 
 T08 DESCRIPTION OF COLOR PLATES. 
 
 the original one has replaced the lost cord. <S. Represents the condition 
 of the larynx three years after hemilaryngectomy in a patient fifty-one 
 years of age. Thyrotomy revealed such extensive involvment, with an 
 open ulceration which had reached the perichondrium that the entire left 
 wing of the thyroid cartilage was removed with the left arytenoid. A 
 sufficiently wide removal was accomplished without removing any part 
 of the esophageal wall below the level of the crico-arytenoid joint. There 
 is no attempt on the part of nature to form an adventitious cord on the 
 left side. The normal arj^tenoid drew the normal cord over, approxi- 
 mately to the edge of the cicatricial tissue of the operated side. The 
 voice, at first a very hoarse whisper, eventually was fairly loud, though 
 slightly husky and inflexible. !>. Mouth of the esophagus one year after 
 laryngectomy for endothelioma in a man aged sixty-eight years. The 
 purple papillae anteriorly are at the base of the tongue and from this 
 the mucosa slopes downward and backward smoothly into the esophagus. 
 There are some slight folds toward the patient's right (to the left in 
 the illustration) and some of these are quite cicatricial. The epiglottis 
 was removed at operation. The trachea was sutured to the skin and 
 did not communicate with the pharynx. Indirect view. 
 
 PIRATE III. 
 
 ES0PH.\G0SCOPIC VIEWS. 
 
 1. Direct view of the larynx and laryngophars'nx in the dorsally 
 recumbent patient, the epiglottis and hyoid bone being lifted with the 
 direct laryngoscope^ or the esophageal speculum. The spasmodically 
 adducted vocal cords are partially hidden by the overhang of the spas- 
 modically adducted ventricular bands. Posterior to this the aryepiglottic 
 folds ending posteriorly in the arytenoid eminences are seen in apposi- 
 tion. The esophagoscope shottld be passed to the right of the median line 
 into the right pyriform sinus, represented here by the right arm of the 
 dark crescent. 
 
 2. The right pyriform sinus in the dorsally recumbent jiatient. The 
 eminence at the upper left border corresponds to the edge of the cricoid 
 cartilage. 
 
 ;i. The cricopharyngeal constriction of the esophagus in the dor- 
 sally recumbent patient, the cricoid cartilage being lifted forward with 
 the esophageal si)eculum. The lower (posterior) half of the lumen is 
 closed by the fold corresponding to the orbicular fibers of the cricophar- 
 yngeus, which advances spasmodically from the posterior wall. (Com- 
 pare Kig. 10). This view is not so clearly obtained with an esophagoscope.
 
 5 6 7 8 
 
 ESOPHAGOSCOPIC VIEWS. NORMAL. 
 
 m 
 
 10 
 
 \z 
 
 13 14 15 16 
 
 ESOPHACOSCOPIC VIEWS. ABNORMAL. 
 
 PLATE III. 
 
 I'lioto^rapliic reproductions of tlie author's oil color-clrawings from life. 
 For description, see previous pages.
 
 ])HSCUIPTIOX OK COUIK PLATES. 709 
 
 4. Passing through tlie right pvriform sinus with the esophagoscope ; 
 dorsally recumbent patient. The walls seem in tight apposition, and, at 
 the edges of the slit-like lumen, bulge toward the observer. The direc- 
 tion of the axis of the slit varies, and in some instances it is like a 
 rosette, depending on the degree of spasm. 
 
 5. Cervical esophagus. The lumen is not so patulent diunng in- 
 spiration as lower down ; and it closes comijlctely during expiration. 
 
 C>. Thoracic esophagus. Dorsally recumbent patient. The ridge 
 crossing above the lumen corresponds to the left bronchus. It is seldom 
 so prominent as in this patient, but can always be found if searched for. 
 
 7. The esophagus at the hiatus. This is often mistaken for the 
 cardia by esophagoscopists. It is more truly a sphincter than the cardia 
 itself, and in the author's opinion it is questionalile if there is any truly 
 spliincteric action at the cardia. It is the spasmodic closure of this 
 hiatal sphincter that ])r()duces the syndrome called "cardiospasm."' 
 
 S. View in the stomach with the o])en-tube gaslroscope. The forms 
 of the folds vary continually. 
 
 9. Sarcoma of the jjosterior wall of the upper third of the esojih- 
 agus in a woman of thirty-one years. Seen through the esophageal spec- 
 ulum, patient sitting. The lumen of the mouth of the esophagus, much 
 encroached upon by the sarcomatous infiltration, is seen at the lower 
 part of the circle. 
 
 10. Coin (half-dollar) wedged at the upper thoracic aperture of a 
 boy aged fourteen years. Seen through the esophageal speculum, recum- 
 bent patient. Forceps are retracting the superjacent cricopharyngeal fold 
 preparatory to removal of foreign body. 
 
 11. ^'ungating, squamous-celled epithelioma in a man of seventy- 
 four years. Fungations are not always present, and are often pale and 
 edematous. The appearance of malignancy may be masked by intlam- 
 mation due to mixed infections. 
 
 12. Cicatricial stenosis of the esophagus following the swallowing 
 of lye in a b(i\' of four years. Helow the up|)er stricture is seen a sec- 
 ond stricture. .\ third one, not shown, was located eccentrically farther 
 down. An ulcer surrounded by an inflammatory areola and the granula- 
 tion tissue togetiier illustrate the etiology of cicatricial tissue. ■ The fan- 
 shaped scar is really almost linear but it is viewed in jiersiJective. Patient 
 was cured by esoi)bagoscopic dilatation. 
 
 1^1. Angioma of the esophagus in a man of forty years. The pa- 
 tient had hemorrhoids and varicose veins of the legs. 
 
 14. Luetic ulcer of the esophagus, 2Ci cm. from the upper teeth, in 
 a woman of thirty-eight years referred for dysphagia. Two scars from
 
 710 DESCRIPTION OF COLOR PLATES. 
 
 healed ulcerations are seen in perspective on the anterior wall. Branch- 
 ing vessels are seen in the livid areola of the ulcers. 
 
 15. Tuberculosis of the esophagus in a man of thirty-four jears. 
 No vessels are visible near the grayish-white patches. A specimen of tis- 
 sue removed esophagoscopically was reported by Dr. Ernest \\". \\ illetts 
 to be tuberculous. 
 
 ](). I.eucoplakia of the esophagus near the hiatus in a man aged 
 fifty-six years. 
 
 PLATE IV. 
 
 Fig. 122 and Fig. 123. Mews obtained by suspension laryngoscopy. 
 For descriptions see Chapter \TII. 
 
 PLATE V. 
 
 Upper illustration. A, gastroscopic view of a gastrojejunostomy 
 opening drawn patulous by the tulie mouth. (Gastrojejunostomy done 
 by Dr. George L. Hays.) B, carcinoma of the lesser cuvalure. (Patient 
 afterward surgically explored and diagnosis verified by Dr. John J. 
 Buchanan.) C, healed i)erforated ulcer (patient referred by Dr. John 
 W. Boyce). 
 
 Lozver illustration. Drawn from a case of post-diphtheritic sub- 
 glottic stenosis cured by the author's method of direct galvano-cauteriza- 
 tion of the hypertrophies. A, immediately after removal of the intuba- 
 tion tube, hypertrophies like turbinals are seen projecting into the sub- 
 glottic lumen. B, five minutes later. The masses have now closed the 
 lumen almost completely. The patient became so cyanotic that a bron- 
 choscope was at once introduced to prevent asphyxia. C, the left mass 
 has been cauterized by a vertical application of the incandescent knife. 
 D, completely and permanently cured after repeated cauterization. 
 
 PLATE VI. 
 
 Endoscopic views through the Janeway gastroscope. A. Looking in 
 the direction of the pylorus. B. View toward the fundus. From illustra- 
 tions furnished by Henry Janeway.
 
 
 
 c 
 o 
 
 -a 
 
 o 
 
 c 
 
 o 
 
 t- 
 
 o 
 u 
 
 c 
 o 
 
 u 
 
 s 
 
 O 
 
 u 
 D. 
 U
 
 Gastroscopic Views. 
 
 Direct Laryngoscopic Views. 
 PLATE v. 
 Reproductions of oil color-drawings from life by the autlior.
 
 PLATE \I. 
 Views through the lens-system gastroscope. For descrijition, see previous pages.
 
 INDEX 
 
 Abscess, bronchiectatlc, 78 
 
 due to presence of foreign body, 
 
 in right inferior lobe bronchus, 
 localization of, 230 
 lung, radiograph of, 405 
 of esophagus from foreign body 
 
 trauma, ;io9 
 pulmonary. 78 
 
 nontuberculous, 237, 476 
 retropharyngeal, 92, 185 
 Actinomycosis of the esophagus, 566 
 Adrenalin, 56, 63 
 
 effect of, on color of bronchoscopic 
 image, 175 
 Air passage, removal of foreign body 
 
 from upper, 88 
 Alcohol, 117 
 
 in treatment 
 larynx, 423 
 Alcoholism, 75 
 Alkalies and cicatricial stenosis 
 
 esophagus, 522 
 Amyl nitrite, 56, 59. 74 
 capsule, need of. 46 
 Amyloid tumors of trachea. 433 
 Analgesia in peroral endoscopy, 54, 
 Anatomical knowledge necessary 
 
 bronchoscopy and esophagoscopy, 
 Anesthesia, advantages of slight, 
 bronchoscopy, 30 
 
 arrested respiration during. 473 
 effect of, on color of bronchoscopic 
 
 image, 175 
 Elsberg. 60 
 
 esophagoscojjy without. 193 
 ether, rectal. 64 
 for bronchoscopy In adults, 466 
 in children. 172, 466 
 indirect laryngoscopy for diag- 
 nosis, 266 
 in children, contraindication 
 for, 126 
 for esoi)hagOKCopy. 55. 56. (;o. 72. 
 ISO, 492 
 laryngostomy, 633 
 peroral endoscopy, 54, 72 
 removal of benign growth of 
 
 trachea, 435 
 tracheotomy, 596 
 work on dogs, 204 
 
 of papillomata of 
 
 of 
 
 72 
 
 for 
 
 52 
 
 in 
 
 Anesthesia, general, 60-64, 72, 89, 91, 94 
 for direct laryngoscopy, posi- 
 tion during, S3 
 in dyspneic children, dangers 
 of, 126 
 fluoroscopic foreign body 
 work, 295 
 technic for, 58, 59 
 In adolescents, 63 
 
 bloody oiierations, 67 
 bronchoscopy, 162, 301 
 buccal operations, 67 
 children under 6 years, 72, 172 
 esophagoscopy, 330, 360 
 infiltration, for tracheotomy, 59S 
 in foreign body removal, 355, 356 
 gastroscopy, 572 
 laryngeal operation, 67, 103 
 laryngectomy, 669 
 nasal operations, 67 
 pharyngeal operations, 67 
 prolonged operations, 67 
 removal of papillomata of 
 larynx in children, 425 
 insufflation, 65, 66, 72, 73 
 
 rules for administration of, 
 69, 72 
 in Ihyrotomy for malignant laryn- 
 geal disease, 661-663 
 tracheotomized patient, 599 
 intratracheal insufflation anes- 
 thesia in thoracotomy, 320 
 in tuberculars, 152 
 local, 64, 65, 94, 96 
 
 author's technic for, 58 
 general rules for, 56, 57, 58 
 in thyrotomy, 65, 662 
 tracheotomy. 598 
 Anesthetic solutions, Yankauer's cuiis 
 
 for, 41 
 Anesthetist, i)osition of. in head and 
 
 neck surgery, 67 
 Anesthetizing attachment for broncho- 
 scope, Buchanan, 22, 59, 68 
 Aneurysm, ,53, 64, 248, 484 
 
 invading trachea simulating 
 tumor, 434 
 Angioma, impossibility of removing, 
 under cocain. 60 
 subglottic, 104 
 Angioneurotic edema, 488
 
 INDEX. 
 
 Anterior commissure, exposure of, 94, 
 
 100, 106, 124 
 Antliracosis, 298 
 Antibeeliics, 57, aOl, 482 
 Antiperistalsis, 55 
 Antipyrin, 56 
 
 Aplionia, liysterical, suspension laryn- 
 goscopy in, 154 
 Apnea following tracheotomy, 598 
 
 vera, 60, 601 
 Apparatus, Elsberg, 60, 64, 66 
 Applicator, Sajous, 64 
 Argyrol in esophageal diseases, 498, 499 
 Arsenic to prevent recurrence of 
 
 laryngeal papillomata, 149 
 Artificial respiration, 56, 62, 67, 74 
 Arytenoid, accidental removal of large 
 part of left, 105 
 
 eminence, right, 188 
 traction of, necessary for produc- 
 tion of adventitious cord, 114 
 region, infiltration of, 205 
 Arytenoids, 94 
 Aryepiglottic fold, 93 
 Asepsis, need of, 46 
 
 Asphyxia due to thymic compression 
 stenosis, 472-476 
 
 tracheotomy in, 588 
 Asphyxiation, 67, 245 
 Aspirating canal, author's, 21, 28, 29, 30 
 pump, Ingals' electric, 28 
 syringe, 28, 29 
 AsiJiration, swab, 53 
 Aspirator for esophagoscopy, 29 
 
 nozzle for, for freeing fauces and 
 
 pharynx from secretions, 29 
 Yankauer's, 28 
 Aspirators, 28-31, 163 
 Assistants during endoscopy, 47 
 Asthma, bronchial, 478 
 Atelectasis in foreign body cases, 299 
 Atroi)ine, 63 
 
 Autoplasty after laryngostomy, 642-644 
 Autoscope, Kirstein, 17 
 Bandage gauze for endoscopic sponges. 
 
 31 
 Bands, false, 93 
 
 ventricular, 94, 236 
 Basket, Graefe, 452 
 Batteries. 26-28 
 
 on operating table, arrangement 
 of, 49 
 Battery, author's endoscopic, 27, 28 
 Bechic blast, 236, 242 
 Bismuth for foreign bodies in stric- 
 tured esophagus, 357 
 subnitrate in esophagitis and trau- 
 nuitic ulcerations, 498 
 Bite blo.k, thimble, 38, 39, 163 
 Blind method of intubation, 75 
 Blood, removal of, during bronchos- 
 copy, 30 
 
 Bougie, eyed, author's, 43 
 in esophageal cases, 218 
 filiform, for minute cicatricial 
 
 strictures of esophagus, 44 
 olive, Plummer's double, 42 
 Bouginage per tubam in stenosis of 
 
 esophagus, 532 
 Bromides, 56 
 
 Bronchi, diseases of, bronchoscopy in, 
 465 
 
 endoscopic appearance of, 177 
 
 exploration of, 163 
 
 foreign bodies in, 20 
 
 in pneumothorax, endoscopic view 
 
 of, 487 
 stenosis of, compression. 470, 476 
 Bronchial asthma, 478 
 Bronchiarctia, 477 
 Bronchiectasis, 234, 248, 298, 477 
 
 bronchoscopy in, 465 
 Bronchitis, gangrenous, after aspira- 
 tion of foreign body, 299 
 
 due to chloroform poisoning, 62 
 peanut, 238 
 treatment of, 47 
 Bronchoscope, 16, 19, 20, 21, 23, 30, 73, 
 74, 77 
 and forceps, preliminary practice 
 
 with, 201 
 author's, 20, 22, 23 
 Briinings, 103 
 
 introduction of, 174 
 Buchanan's dosimetric anesthetiz- 
 ing attachment for the, 22, 484 
 correct holding of, 168 
 depth of insertion in, 171 
 held in left hand, 166 
 incorrect holding of, 168 
 Ingals' distally illuminated, 12, 13 
 in position after removal of laryn- 
 goscope, 167 
 recumbent patient. antero- 
 posterior and lateral radio- 
 graph of, 223 
 right and left main bronchi 
 
 entering the. 169 
 upper lobe bronchus, radio 
 graph of. 165, 222 
 into middle lobe bronchus, enter 
 ing, 170 
 right and left main bronchi 
 
 entering. 169 
 upper lobe bronchus, entering, 
 
 171, 172 
 various branch bronchi, en 
 tering, 170 
 in trachea, position of. during ar 
 
 tificial respiration, 74 
 introduction of, 58, 59, 70, 75, 155- 
 177 
 difficulties in. 161
 
 INDEX. 
 
 Bronchoscope, introduction ol', patient 
 recumbent, 157 
 
 sitting, 15.T 
 through glottis, 159 
 Kaliler, K5, 103 
 
 introduction of, 175 
 removal of 254 
 sizes of, 20, 21, 22 
 slanted end, lti9, 170 
 
 for entering branchi bronchi, 
 172 
 sliding double-tubo, of Schoon- 
 
 maker, 13 
 use of author's, for subglottic 
 laryngoscopy in children, 102 
 
 Bronchoscopic appearance in disease, 
 467 
 
 image, normal, 175 
 oxygen insufflation, 73 
 picture in asthma, 478 
 removal of benign growths of 
 trachea, 434 
 
 Bronchoscopy, 17, 25, 30, 32, 60, 68,84,92 
 best time for, 301 
 Boyce position during, advantages 
 
 of, 1(J4 
 by Briinings' method, 173 
 contraindicationo for, 466 
 dilTuulties of, 200 
 during tracheotomy, 601 
 fatigue in children after, 262 
 lluoroscopic, 295, 303 
 for forf'ign bodies, complications 
 and after-effects of, 258-265 
 in children, fil-63. 250 
 nicchaiiical |)roblems of, 270 
 mortality and results of, 245- 
 
 265, 270 
 of prolonged sojourn, indica- 
 tions for, 299 
 malignant growths of trachea, 
 
 442-443 
 removal of secretions, 484 
 tacks from bronchus. 209 
 unsuccessful cases of, 318-327 
 hemiiilcgia during, 262 
 in iliilclrcu, 172 
 indications for, 465 
 in diseases of trachea and lironrlil. 
 46.5-488 
 tuberculosis of tracheobronchi- 
 al tree, 485-486 
 oral, anesthesia in, 56, 60, 61, 62 
 
 schema illustrating, 156 
 position for, 77, 78-80, 82, 83-86 
 reactions following, general, 261- 
 262 
 local, 262 
 secretions during, 63 
 trachootomic. 56, 171, 2.55-258, 326 
 versus oral, 164, 255 
 
 Bronchotracheal inflammations and 
 
 their sequelae, 476 
 Bronchus, abscess in right inferior 
 lobe, 230 
 anterior branching, entrance ot 
 
 170 
 branch, entrance of, 170 
 entrance of, with slanted-end 
 
 bronchoscope, 169 
 diverticulum in left, complicating 
 
 tuberculosis, 486 
 left, entrance of, 169 
 middle lobe, entrance of, 170 
 protector, Briinings', 275 
 right, entrance of, 169 
 stenosis of, 248 
 
 upper lobe, entrance of, 171, 172 
 exploration of. 467 
 Cadaver for study of anatomy, use ot, 
 52, 202 
 
 practice on, 76, 203 
 Caliper guide method of localization, 
 Boyce, author's modification of, 219, 
 231 232 
 Cancer, infectiousness of, 666 
 of esophagus, 444-449 
 
 symptoms of, early, 446 
 of larynx, 647 (see laryngeal can- 
 cer) 
 resection of thoracic esophagus in, 
 450 
 Cancerous stenosis of the esophagus, 
 
 529 
 Cannula, breaking off of, in situ, 608 
 cane-shaped, author's, 472, 474, 589 
 cleansing of, 608 
 defective, 591 
 emergency, 591 
 
 for various ages, tracheotomic, 
 size and radius of curvature of 
 author's, 591 
 full-curved, gauze used to hold 
 
 out long, 591 
 llahn, 668 
 
 laryngostomy, author's. 628, 629 
 T-shaped separable tracheal, 
 628-629 
 obstruction of, 609 
 snare, heavy, 39, 40 
 tampon, 66 
 Trendelenberg, 668 
 tracheotomy, 65, 589, 607 
 valve, IJe Sanll, 590 
 Carcinoma, laryngeal, 107 
 
 mesnthorium treatment of, 154 
 of epigloUis, removal of, under 
 siisiiension laryngoscopy, 154 
 Cardia. hiatal constriction mistaken 
 
 for, 191 
 Cardiac failure, 67, 74, 91 
 Cardiospasm, 55, 505, 507, 510-521 
 treatment of, 519
 
 INDEX. 
 
 Carina as an aid in diagnosis, respira- 
 tory movement of, 467 
 
 identification of, 166, 168, 169 
 
 broncliial orifices in disease 
 of, 169 
 position of, relative to long axis 
 of trachea, 240 
 Catheter, insufflation, 66, 68, 69 
 introduction of, 71, 72 
 silk-woven, 61, 63, 66 
 Cervical cellulitis after endolaryngeal 
 
 operations, 118 
 Chest, physical examination of, 234 
 Children, holding of, for examination, 
 
 86-87 
 Chloroform, 58, 59, 61, 63, 68, 125, 210 
 and morphine in bronchoscopy, 162 
 effect of, on color of bronchoscopic 
 
 image, 175 
 in endoscopy for foreign bodies, 
 402 
 esophagoscopy for foreign 
 
 bodies, 339 
 suspension laryngoscopy in 
 
 children, 143 
 thyrotomy, 663 
 Cicatricial stricture of esophagus, site 
 
 of, 525 
 Circuits, commercial, 28 
 Clamps, hemorrhage, 150. 152 
 Closure of air-passages to food during 
 
 swallowing. 111 
 Clubbed fingers in foreign bodv case, 
 
 314-315 
 Cocain, 56, 57, 58, 60, 62, 63, 64, 72, 106 
 126 
 effect of, on color of bronchoscopic 
 
 image, 175, 478 
 for paralyzing animal foreign 
 bodies in tracheobronchial tree, 
 293 
 idiosyncrasy to, 118 
 in suspension laryngoscopy, 134, 
 142, 143 
 tracheotomy, 598 
 rules for use of, 57, 58 
 Cocain-adrenalin in thyrotomy 662 
 Codein, 63 
 
 Coin in hypopharynx, removal of, 154 
 Constriction, cricopharyngeal, 188 
 Constrictions in the esophagus, 52 
 Cord, accidental removal of posterior 
 half of, 105 
 
 necessity of, for proper phonation, 
 114 
 Cords, adventitious vocal, endolaryn- 
 geal operations favoring develop- 
 ment of, 112, 429 
 
 exjjosure of vocal, 98 
 growths on vocal, 89, 93 
 vocal. 94, 236 
 
 Cords, vocal, nodules on, 151, 420 
 
 plionation for identification of, in 
 
 direct laryngoscopy, 123 
 polypus of, 154 
 Cough as symptom of foreign body in 
 esophagus, 332 
 
 croupy, in children, 92 
 tracheoesophageal wall during, en- 
 doscopic view showing forward 
 bulging of posterior mem- 
 branous, 177 
 Cough-reflex, abolition of, 54, 56, 58, 
 68, 72, 78 
 absence of, in influenzal tracheitis, 
 
 482, 
 preservation of, 308, 636 
 Counter-pressor for suspension laryn- 
 goscopy, 141 
 
 Killian, for suspension laryn- 
 goscopy, 141 
 Crayons for sketching endoscopic 
 
 image, 204 
 Cricoarytenoid joint, injury to, 196 
 Cricoid cartilage, 188, 192 
 Crieoi)haryngeal fold, 186 
 
 spasmodic stenosis, 508-510 
 Cricopharyngeus, difficulty of passing, 
 188 
 spasmodic constriction of, 561 
 spasm of, secondary to gastric dis- 
 ease. 506 
 Cricothyroidotomy, 593, 602 
 Cup for anesthetic solutions, Yan- 
 
 kauer's, 41 
 Curette, double, 149, 152 
 
 reversible, 148, 152 
 Cyanosis, 64, 118 
 Death-space of Meltzer, 67 
 Decannulation, 113, 610 
 
 after cure of laryngeal stenosis, 
 
 645-646 
 difficult, in laryngeal stenosis, 612- 
 621 
 Dental protector, Mosher's laryngeal 
 
 spatula with, 19 
 Diagnosis, taking a laryngeal specimen 
 
 for, 107 
 Diathermy in treatment of inoperable 
 
 malignancy, 441 
 Difficulties in direct laryngoscopy, 100 
 Dilatation in stenosis of esophagus, 531 
 of chronic laryngeal stenoses, in- 
 tubational, 622-627 
 Dilator, esophageal, Jlosher's, 42 
 
 for bronchoscopic dilatation of 
 bronchial stricture, 41, 302, 
 308 
 endoscopic use in bronchial 
 and esophageal stricture, 41, 
 44, 533 
 Trousseau. 599, 604, 609 
 Diphtheria, anesthesia in, 126
 
 INDKX. 
 
 Uiplitheria. iiiftuenzal, laryngo-trachei- 
 tis, simulating, 481 
 
 laryngeal, foi'eign body diagnosed 
 
 as, 266-267 
 subglottic edema in children after, 
 115 
 hyperplasia in chiklrcn after, 
 115 
 cases, cannula in, obstruction of, 
 609 
 Direct laryngoscopy (see laryngos- 
 copy ) 
 Disease high up in esophagus, 26 
 Distal illumination. M, 15, IG, 23, 24, 
 
 27, 28 
 Distance, estimation of, 201, 203, 272 
 273 
 
 Diverticulum due to cicatricial steno- 
 sis, 52!t 
 
 esophageal, 53, 540-556 
 of esophagus, after-care following 
 operation for, 556 
 pressure, 542 
 pulsion, 541-556 
 
 diagnosis of, 545 
 etiology of, 541 
 filled with bismuth mix- 
 ture, 544, 545 
 prognosis of, 543 
 recurrence of, 549 
 symptoms of, 544 
 treatment of. 550 
 suspected, esophagoscopy in 
 
 cases of, 546 
 traction, 540 
 of Zenker, pulsion. ISO 
 
 Divulsor, 41, 308 
 
 expanded in living patient, 520 
 for treatment of esophageal sten- 
 osis, 533 
 Dog, practice on, 203 
 Dosimetric anesthetizing attachment 
 for bronclioscope. Buchanan's, 22, 59. 
 68 
 Drainage canal, .lulhor's esophago- 
 scope and gastroscope with, 24, 78 
 tube, 74, 77 
 Drowning of patient in his own se- 
 cretions, 482-484 
 Dysphagia, 1 1 1 
 
 following esophagoscopy, 195 
 
 Dyspnea, 56, 59, 62, 67, 77, 92, 109, 112, 
 115, 125, 126, 128, 161, 185 
 as symptom of foreign bodies In 
 
 esophagus, 332 
 bronchoscopy in, 249, 465, 5S6 
 due to foreign body in larynx, 
 
 traclieotomy for. 267 
 lns|iiralory. without laryngeal ob- 
 struction. 481 
 
 Dyspnea, laryngeal, following endo- 
 laryngeal operation. 117. 118 
 sudden death in, factors in, 585 
 suspension laryngoscopy in pres- 
 ence of, 149 
 Echinococcus of lung. 433 
 Kdema, angioneurotic, 488 
 
 annular, 283, 284. 287. 290 
 esophageal, angioneiirotic. 5(;5 
 laryngeal, 22, .53, 108, 118, 263, 580 
 in suspension laryngoscopy. 153 
 subglottic, 102, 115. 116, 130, 160, 
 460 
 cause of, during bronchosco))y, 
 
 263 
 due to pressure on larynx dur- 
 ing bronchoscopy, 163, 257 
 in children, 172 
 post-diphtheritic, 622 
 tracheotomy in, 593 
 treatment of, 2(55 
 supraglottic laryngeal, 262 
 tracheal, invisibility of ring in, 
 177 
 Electrode for galvano-cauterizations, 
 
 42, 117 
 Electrolysis in esophageal stenosis, 537 
 Emetics in foreign body work, 338 
 Emphysema in foreign body cases, 299 
 of neck following endolaryngeal 
 operation. 1 IS 
 Enchondroraa of tracheobronchial tree, 
 
 432 
 F^ndobronchial treatment, 467 
 Endolaryngeal extirpation of papil- 
 lomata of larynx, 425 
 operations. 20 
 
 after-care following, 117 
 
 during. 118 
 complications during. 118 
 danger signs following, 118 
 favoring development of ad- 
 ventitious vocal cords, 112- 
 114 
 Endoscopic appearances in tracheo- 
 broncliial tree and esophagus, varia- 
 tions of, 52 
 
 of benign growths in tracheobron- 
 chial tree. 434 
 
 child's larynx, 128 
 esophageal jiaralysis, 560 
 foreign bodies in esophagus, 
 
 341 
 laryngeal disease, 460 
 evisceration of larynx for cicatri- 
 cial stenosis. 1 13 
 excision in unsuccessful cases of 
 bronchosco|)y for foreign bodies, 
 318 
 foreign body extraction, rules for, 
 
 293 
 image obtained by suiiraglottic 
 tracheoscopy. 131
 
 ■VI 
 
 INDEX. 
 
 Endoscopic use of laryngeal forceps, 
 103 
 
 view at end of second stage of di- 
 rect laryngoscopy, 123 
 Endoscopy for foreign bodies in air 
 and food passages, illustrative cases 
 of, 402-419 
 
 in children, 58 
 
 malignant disease of larynx, 
 437-441 
 instructions to patients for, 95-96 
 mechanical ingenuity necessary 
 
 for, 26 
 peroral, anesthesia for, 54-62 
 position of patient for, 77-88 
 removal of secretions in, 29 
 shock after, 261-262 
 Enteroclysis, 53 
 
 Epiglottis, 91, 92, 94, 96, 98, 99, 236 
 amputation of, for palliation of 
 dysphagia, 111 
 in tuberculosis, 112, 462 
 carcinoma of, removal of, 154 
 cause of failure to expose, 124 
 downward traction of, 96, 98, 99 
 elevation of, 121 
 exposure of, 121 
 identiflfation of, 69, 96, 97, 99, 101, 
 
 121 
 malignant disease of, 438 
 Reichert hook for raising, 140, 144 
 of children as seen with direct 
 laryngoscope, 128-130 
 Epiglottis-spatula, use of, 145 
 Esophageal diverticulum, recurrence 
 of, 549 
 
 function after prolonged sojourn 
 
 of foreign bodies, 335 
 mucosa, 192 
 occlusion in foreign body cases, 
 
 author's symptoms of, 332 
 rejjair after laryngectomy, plastic, 
 
 672 
 resection, 673 
 spasmodic stenosis, age as factor 
 
 in, 507 
 stenosis, pvriform sinuses in, 491, 
 
 500 
 wall, weak point in, 186 
 Esophagismus, 55 
 
 abdominal, 514, 515 
 
 nerve-cell habit as a factor in. 
 506 
 hiatal, 510-521 
 
 diagnosis of, 517 
 
 simulating diverticulum, 516- 
 
 519 
 treatment of, 519 
 in now-born, 507 
 Esophagitis, acute, 362, 495 
 chronic, 499, 523 
 
 treatment of, 499 
 
 Esophagites, from blind efforts to re- 
 move foreign body, 337-338, 362 
 Esophagoscope, 19, 21, 23. 24, 25, 26. 
 30, 74 
 
 anchoring of, 187 
 angular, 13, 14 
 author's, 24 
 
 Briinings', introduction of, 197 
 Einhorn, 19 
 
 for esophageal diverticula, au- 
 thor's, 546 
 Guisez, 15 
 Hill, 18 
 
 introduction of, 55, 88, 178-198 
 by sight, 187 
 patient recumbent, 187 
 stages in, 1S7 
 Kahler, 13 
 
 technic of introducing, 197 
 light-carrier during withdrawal of, 
 
 194 
 Mosher. 13, 14 
 reinsertion of, 194 
 sizes of author's. 342 
 slanted-end, author's, 189 
 
 position of. in recumbent pa- 
 tient, 188 
 Esophagoscopic aid in excision of di- 
 verticulum, 551 
 
 appearances and diagnosis of ci- 
 catricial stricture, 527 
 malignant disease of esoph- 
 agus, 446 
 appearances in esophageal lues, 
 562 
 tuberculosis, 564 
 appearances of spasmodic stenosis 
 
 at cricopharyngeus, 509 
 extraction of foreign bodies, 341 
 image, 192 
 
 removal of foreign bodies, me- 
 chanical problems of, 346-362 
 views in cases of diverticulum, 547 
 Esophagoscopy, 25, 28, 32, 53, 60, 78 
 anesthesia for, 55, 56, 58, 60, 61, 62, 
 
 64, 180 
 asiJirator for, 29 
 complications following, 195 
 
 precipitated by, 197 
 difficulties of, 193, 200 
 downward escape of foreign body 
 
 in, 61 
 fluoroscopic, 359 
 
 for determining advisability of op- 
 eration for laryngeal malig- 
 nancy, 438 
 esophageal disease, contrain- 
 dications in. 490-491 
 technic of, 492 
 foreign bodies. 339-362 
 
 complications and dan- 
 gers of, 360-362
 
 INDEX. 
 
 Esophagoscopy for foreign bodies in 
 cliildren, 61, 62 
 
 instruments for, 341 
 mortality of, 337, 339-340 
 results of, 339 
 higli-Iow method of, author's, 79, 
 
 189-193 
 in cases of suspected diverticulum. 
 546 
 diagnosis of esophageal diver- 
 ticulum, iJ46 
 indications and contraindications 
 
 for, 178 
 in esophageal disease, indications 
 for. 489 
 foreign body cases, contrain- 
 dications to, 340 
 injuries from forcilile unskilled at- 
 tempts at, 196 
 in new-born, 490, 492, .'.07 
 
 spasmodic stenosis of the 
 
 esophagus, ."jO.'j 
 suspected foreign body cases, 
 
 indications for, 340 
 suspension. I."i4 
 position for, 77, 78, 80, 83-86 
 pyriform sinus in, author's meth- 
 od of finding. 188 
 retrograde, in esophageal stenosis, 
 
 537 
 specular, IS.") 
 
 technic of, 185 
 Esophagotome, string-cutting, author's, 
 
 43, 5.37 
 Esophagotomy, external, for removal 
 of foreign body, 33.'., 33 
 
 internal, in esophageal stenosis, 537 
 Esophagus, accidental entrance of, in 
 bronchosco|)y. 161 
 actinomycosis of, 566 
 anomalies of, 492-495 
 
 treatment of, 494 
 artilicial denture in, 417 
 l)allooning of, according to Mosh- 
 
 er method, 195 
 cancer of, esophagoscopic appear- 
 ance of, 446 
 cicatricial stenoses of the, 26 
 constri<'tioiis in. 52 
 
 cricopharyngeal, 179. 180 
 
 dermal fla|i oi)eration for repair 
 
 of, 673 
 deviation of, 566-567 
 dilatation of, diffuse. 502 
 
 treatment of ditfuse, 503 
 direction of. 182 
 diseases of, 489-567 
 disease of. diagnosis of, 489 
 
 esojihagoscopy in, 489-492 
 
 indirect examinations in. 491 
 
 symptoms of, 490 
 diverticulum of. 540-556. 
 
 Esophagus, diverticulum of, after-care 
 following operation for, 556 
 
 diagnosis of pulsion, 545 
 difficulty in excision of, 552 
 examination of, 548 
 pulsion, 541-556 
 removed by Gaub method, 5.53- 
 
 555 
 traction, 540 
 use of bismuth in, 546 
 edema of, angioneurotic, 565 
 imperforate, 492, 494 
 imjjlantation metastases in, 445 
 in esophageal cases, emptying of, 
 
 53 
 inflammation and ulceration of, 
 495-498 
 treatment of acute and sub- 
 acute, 498-499 
 interventions in, 151 
 intubation of, for stenosis, 539 
 lues of, 561 
 
 treatment of, 562 
 malignant disease of, 444-459 
 diagnosis of, 444 
 differential diagnosis in, 449 
 removal of specimen in, 444- 
 
 445 
 intubation in, 450 
 site of, 444 
 treatment of, 449-459 
 Mosher's device for ballooning, 24 
 narrowing of aortic, 181 
 apertural, 181 
 bronchial. 182 
 distance from upper teeth of. 
 
 182-184 
 hiatal, 182 
 normal, 178 
 spasmodic, 178-1.82 
 neoplasms of, benign, 436 
 paralysis of, 329, 557-561 
 diagnosis of, 560 
 endoscopic appearances of, 
 
 560 
 etiology of, 560 
 motor, 559 
 treatment of, 561 
 perforation of. in foreign body 
 
 work, 361 
 pliysiological constrictions of, 179 
 relative jiosition of trachea and, 79 
 rupture and trauma of, 494-495 
 sensation in, paralysis of, 557-559 
 spasm of, etiology of, 505 
 
 symptoms of, 505 
 speculum for oiiorations upon 
 
 upper end of the, 25 
 stenosis of, cicatricial, 522-539 
 
 classification of impermeable, 
 
 538 
 compression, 499-503
 
 Vlll 
 
 INDEX. 
 
 Esophagus, stenosis of, congenital, 
 493, 494 
 
 decomposition of food in, 527 
 eccentric, witli interstrictural 
 
 sacculations, 533-536 
 diet in, 533-535 
 differential diagnosis in, 528- 
 
 530 
 foreign bodies in, 356 
 rest in, 530 
 spasmodic, 504-521 
 stenotic conditions of, 26, 194 
 strictures of, (see stenosis) 
 surgical intolerance of, 196 
 thoracic, 190, 191 
 tuberculosis of, 563 
 
 treatment of, 565 
 ulceration of. 495 
 ulcer of, differential diagnosis of, 
 
 496-49S 
 varix and angioma of, 565 
 webs in, 494 
 
 congenital, 26 
 Ether, 58, 59, 62, 63, 64, 65, 67, 68, 210 
 in radiogi'aphic work, contrain- 
 dications for, 222 
 insufflation in thyrotomy, 661 
 in suspension laryngoscopy in chil- 
 dren, 143 
 mucus. 68 
 Ethylchlorid, 61 
 
 Extractor, screw-pointed, Richard- 
 son's, 40 
 Extubal method, author's, 110-112 
 Extubation. 624 
 
 difficult, 115 
 Eye, education of, for endoscopy, 44. 
 
 201 
 Fibroma attached to under-surface of 
 right cord, 104 
 
 naso-pharyngeal, anesthesia in re- 
 moving, 67 
 of cord, 420 
 
 primary in tracheobronchial tree, 
 432 
 Films, transparent, author's, 321 
 Finger for hyoid bone elevation, 64 
 Fistula, esophagotracheal, congenital, 
 
 493 
 Fluoroscope, double-plane, Grier. 293. 
 
 295, 577 
 Fluoroscopic esophagoscopy. 359 
 Fluoroscopy in diagnosis of esophageal 
 
 diseases, 489 
 Food debris during esophagoscopy, 79 
 passage, removal of foreign body 
 from, 88 
 Forceps, 20 
 
 alligator punch. 37, 110-112, 269, 
 
 346, 421 
 author's, 32, 33, 34, 35 
 bean. Killian, 291 
 
 Forceps, Briinings, 36 
 care of, 49 
 Casselberry, 36 
 
 claw, in foreign body work, 291 
 delicate, necessity for, in foreign 
 
 body work, 290 
 dilating, author's 41, 302 
 faulty models of, 32-33, 35 
 for direct laryngoscopy, 39 
 
 esophagoscopic removal of 
 
 open safety pins, 36, 351 
 external laryngeal operations, 
 
 author's grasping, 635 
 foreign body work, 32, 291 
 infant bronchoscopes, 35 
 removing animal foreign 
 bodies, 293 
 in endoscopic foreign body extrac- 
 tion, 272 
 radium treatment, use of, 456 
 jaws for foreign body work, 34 
 Killian's "bean," 32, 34 
 laryngeal, endoscopic, use of. 103 
 lateral movement of. by author's 
 
 method. 274 
 Mathieu's, 32 
 
 Mosher's alligator, 26, 32, 269 
 Paterson's, 32 
 
 pin-cutting, Casselberry's endo- 
 scopic, 36 
 jiointed jaws for author's, 36 
 proper closure of, 34, 274 
 rotation, author's, 35, 36, 269-273, 
 
 286, 347, 351, 353 
 punch, sliding, 37, 38 
 Sajous, laryngeal, 58 
 side-curved jaws for author's, 34, 
 
 257, 277, 283, 302 
 sliding punch, 106, 107 
 tissue, 36, 37, 106 
 tube versus hinged-jaw, 32 
 upper-lobe bronchus, author's, 293, 
 
 294 
 variety of, Heedlessness of, 104 
 Foreign bodies, anesthesia for, 55, 58 
 bechic expulsion of, 242 
 beech nut hull in trachea and 
 
 bronchi, 483 
 bismuth capsules for localization 
 
 of, 224-226 
 blind bouginage in presence of, 
 
 337 
 bolus of meat in esophagus, 328 
 bone at bifurcation, 388 
 in bronchus, 388 
 
 esophagus. 386. 387. 389, 
 
 415 
 radiograph of, 220 
 hypopharynx, 390 
 pharynx and entrance to 
 
 larynx, 148 
 subglottic region, 388 
 trachea, 388
 
 INDEX. 
 
 IX 
 
 Foreign bodies, brass fastener in right 
 bronchus for seven years, 304-306 
 bronchoscopic removal of, failure 
 of. 246 
 general reaction following, 
 
 2.>9-261 
 gravity in, 290 
 in moderately virulent infec- 
 tive tracheobronchitis, 
 260 
 tracheotomized patients, 
 2.'):i-2.').S 
 local reaction following, 262 
 bronchoscopy for, contraindica- 
 tions to, 248 
 choice of time for, 2.")0 
 complications and after-ef- 
 fects of, 2.-)8-26.5 
 contraindications to, 248-249 
 duration of, 250 
 dyspnea after, 262 
 mechanical jjroblenis of, 270- 
 
 296 
 fluorosco|)ic, 295-296 
 mortality and results of, 245- 
 
 246 
 necessity of immediate, 249- 
 
 250 
 unsuccessful cases of, 318-327 
 bullet in bronchial orifice, 401 
 buried in pharyngeal and esoph- 
 ageal tissues, 357 
 button in bronchus, 396, 397, 409 
 esophagus, 397, 398, 414 
 trachea, ;196 
 calcified glands interpreted radio- 
 graphically as, 227 
 cherry stone in esophagus, 340, 394 
 chinaware in larynx, 399 
 classification of, in air and food 
 
 I)assages, 206 
 coal in bronchus, 398 
 
 removal of, 290 
 coin below plica cricopliarvngeus. 
 382 
 in esophagus, 227, 383-385, 414- 
 415, 447 
 and trachea, 382 
 hypopharynx, 382, 384 
 
 removal of, 154 
 trachea, 382 
 collar button in esophagus. 331, 411 
 left bronchus for twenty-six 
 
 years, glass. 310 
 lung, 312, 313 
 
 right bronchus ten years, lead 
 alloy, 305-309 
 cough and, 218 
 coughing up of, 242-244 
 cui'f link ulcerated through esopli- 
 agus into trachea, 333-335 
 
 Foreign bodies, denture al l)ottom of 
 hypopharynx, 399 
 
 in esophagus, 400 
 determination of presence of, 255, 
 
 31 to 
 diagnosis of, on |)liysical and 
 
 laboratory findings, 234 
 digital efforts of removing, 207 
 dilatation in localization of, 302 
 diphtlieritic membrane in trachea 
 
 simulating. 247 
 disk in esophagus, 386 
 downward escape of, during 
 
 esophagoscopy, 330 
 egg shell in larynx, 394 
 embedded, 278-279 
 endoscoi)ic extraction of, rules for, 
 
 293 
 endoscopic findings in, negative,254 
 entering lower air passages, 
 
 gauntlet to be run by, 236 
 eraser, removal of, 290 
 esophagoscopy for, complications 
 
 following, 195 
 fish hook in esojihagus, removal 
 
 of, 353-3.55 
 fixed crosswise in esophagus, ex- 
 traction of, 347 
 flat bone in subglottic space, 148 
 foot of alarm clock in bronchus, 
 
 411 
 forceps for removal of irregular, 35 
 fragments of, removal of broken 
 
 off. 291 
 gastroscopy for, 576 
 glass in subglottic region, 395 
 gourd seed in bronchus, 395 
 grasping of. for removal, 276-277 
 hardware in bronchus, 365-369 
 esophagus, hiatal, 368-369 
 pyriform sinus, 366 
 trachea. .369 
 history sheet for. 214 
 impacted. 5S 
 in adult, dillicult cases of, 63 
 
 air and food passages, 88, 
 206-235 
 endoscopy for, illustrative 
 cases of, 402-417 
 in air passages, color of, 251 
 
 endoscopic ai)pearances of, 251 
 etiology of, 236 
 symptoms of, 215 
 in bronchi, 78, 81, 171, 209. 215. 
 296, 304, 365-370, 372-373, 
 379. 3SS, 393-401, 419 
 expulsion of, 242 
 for i)rolonged periods, 297-:'. 17 
 after-treatment following 
 
 removal of, 303 
 author's cases of, 304-317
 
 INDEX. 
 
 Foreign bodies in bronchi for pro- 
 longed periods, bronchoscopy for, 
 299-300 
 
 cicatricial tissue due to, 
 
 303 
 prognosis of, 299 
 stricture due to, 303 
 symptoms of, 224 
 tight-fitting, removal of, 287- 
 
 290 
 voluntary aspiration of, 209 
 in bronchus, large, 227 
 left, 148 
 
 middle lobe, 241 
 right, 148, 239-241 
 upper lobe, 293-295 
 in children, preponderance of, 237 
 indurated ulcer at carina simulat- 
 ing, 247 
 in esophagus, 61, 185. 209, 215, 218, 
 226, 286, 328-338, 368-369, 
 3i'0, 372, 378, 380-392, 394- 
 400, 418, 447 
 age as factor in, 329 
 fatality of, 332-334 
 lodgement site of, 329-330 
 prognosis of, 332, 335 
 prolonged sojourn of, 357 
 removal of broad, sharp-point- 
 ed, 349 
 large, 355 
 spasm and lodgement of, 330 
 strictured, 356 
 symptoms of, 216, 331 
 treatment of cases of, 335, 338 
 in food passages, removal of, 88 
 hypopharynx, 382, 384, 390, 399 
 hysteric and insane, 208 
 larynx, 92, 148, 209, 267, 374, 
 380, 382, 388, 393-395, 399 
 and tracheobronchial tree, 
 
 236-265 
 diagnosis of, 266 
 expulsion of. 242 
 removal of, 55, 57, 78, 88, 
 
 266-269 
 symptoms of, 216-266 
 mouth, 78 
 nasopharynx, 78 
 pharynx, removal of, 78 
 pleura, 401 
 stomach, 208 
 in trachea, 56. 160, 209, 215, 216. 
 234. 286, 369, 373. 379. 381, 382, 
 388. 393. 396 
 
 expulsion of. 242 
 in traclieobroncliial tree, bronclio- 
 scopic finding of. 252-254 
 small animal, removal of, 292 
 soft friable, removal of, 290- 
 292 
 into pleura, bursting of, 310-314 
 
 Foreign bodies, jewelrv in bronchus, 
 370, 372, 373 
 
 esophagus, 370, 372 
 subglottic region, 370 
 "Job's tear" in bronchus, 395 
 lip of bronchoscope for disimpac- 
 
 tion of, 291 
 localization of, 222 
 locket in esophagus, 416 
 lose of, from grasp of forceps, 303 
 magnetic extraction of, 244 
 maize at tracheal bifurcation, 393 
 
 in bronchus. 393. 394-396 
 meat in esophagus, 390-392 
 
 removal of, 356 
 metallic, 238, 284 
 
 capsule in right bronchus, 148 
 molar tooth in bronchus, 226 
 most frequent sites of, 238-241 
 multiplicity of, 247 
 nail in left bronchus, 148, 314-318 
 in trachea for several years, 
 210 
 nails, removal of, 276 
 necessity for removal of secretion 
 
 in presence of. 163 
 needle, extraction of, 276 
 
 in the intestine, 336 
 nurse in presence of, necessity of 
 
 special, 258 
 nut-hull in bronchus, 393 
 olive pulp in esophagus, 394 
 overriding, 343-346 
 paper pulp in esophagus, 396 
 pea in right bronchus, removal of, 
 
 292 
 
 peanut kernel in bronchus, 393, 
 
 394-396 
 
 most fatal of, 238, 261, 262 
 
 pebble in bronchus, 398, 399, 410 
 
 physical examination of chest in 
 
 cases of, 234 
 pin at periphery of lung, 326 
 
 in posterior branch of inferior 
 lobe bronchus, 323, 324 
 pin in pyriform sinus, 375 
 
 right lung not found at bron- 
 choscopy, 322 
 
 pins, 20, 299 
 
 author's method of exposing 
 
 hidden, 253, 278 
 extraction of, 276, 277, 280 
 in air passages, position of, 
 239 
 
 bronchi, 237, 264. 280, 326, 
 
 373-379, 406, 408 
 esophagus, 348, 378 
 larynx, 374 
 
 l)ins in trachea, 373 
 pleuroscopy for, 363 
 plug in bronchus, 398
 
 INDKX. 
 
 Foreign bodies, positive film of tra- 
 clieobronchial tree as aid to localiza- 
 tion of, 227-231 
 
 primer at bottom of pleural cavity, 
 
 364 
 prophylaxis in, 207 
 pyriform sinus as biding place for, 
 
 343 
 radiographic localization of, 219- 
 
 234, 304 
 radiographs of, interpretation of, 
 226 
 misleading negative, 220-221, 
 233 
 radiography of, value of negative, 
 
 231 
 removal of, 26, 78, 148, 199 
 
 by Briinings esophagoscope, 
 
 198 
 by esophagoscopy, 187 
 ring in esophagus, 413 
 rotation in removal of, 269 
 safety pin in esophagus, 380, 381 
 
 in esophagus of infant, 354 
 removal of open, 349, 332 
 
 in larynx, 380 
 of infant, 354 
 
 of child, removal of piece of, 
 148 
 in pharynx removed by sus- 
 pension laryngoscopy, 148 
 in right bronchus of infant 
 
 of 3 montiis, 264 
 in subglottic region, 379 
 trachea, 379, 381 
 of infant, 228 
 open, 56, 284 
 
 lodged point upward at 
 bifurcation of trachea, 
 286 
 safety-pins, open, lodged point up- 
 ward, endoscopic closure of, 286 
 se<retion in presence of, 234 
 shell primer in pleura, 401 
 simulating other diseases, 247, 
 
 267-268, 300, 311, 334, 338 
 small, downward i)rogress of, 229 
 
 in small brondii, 231 
 spontaneous expulsion of, 241 
 staple in bronchus, removal of, 289 
 in esophagus, 412 
 in posterior branch of inferior 
 
 lobe bronchus, 288 
 in right lung. 289 
 lodged upward in esophagus, 353 
 stenosis due to, cicatricial esopha- 
 geal, 524 
 suspected, error to avoid in, 235 
 history of patient and deduc- 
 tions therefrom in case of, 
 1213 
 
 Foreign bodies, suspected, in air pas- 
 sages or esophagus, necessity of 
 bronchoscopy in, 232 
 
 indications for bronchoscopy in, 
 246, 247 
 indirect examination in, 217 
 preliminary examination in 
 
 cases of, 267 
 procedure in cases of, 212-235 
 symptoms, after aspiration of, 213- 
 
 216, 300 
 tacks, double-pointed, in bronchus, 
 removal of, 289 
 extraction of, 276, 280 
 in bronchus, 233, 284, 309, 403, 
 
 405 
 in intestines. 212 
 in posterior branch of right 
 inferior lobe bronchus, 209- 
 211, 213 
 lodged upward in esophagus. 
 
 double-pointed, 353 
 upholstery, mushroom anchor 
 problem of, 281-283 
 with buried point, extrac- 
 tion of, 282 
 thoracotomy for removal of, 326 
 through glottis, bringing, 274 
 tooth in bronchus, 399, 400 
 tooth-plate in esophagus, jiro- 
 
 longed sojourn of, 35 1, 35S 
 tracheotomy for, 584 
 walnut shell in esophagus, 394 
 wandering of, through esophageal 
 
 wall, 255 
 watermelon seed in subglottic 
 larynx, 393 
 in trachea, 393 
 Foreign body work, bronchus in. ru|)- 
 ture of. 280 
 
 dog for practice in, 203 
 fluorescent screen in, 222-224 
 forceps, 32 
 
 gravitation in, necessity for con- 
 sidering. 217 
 Fulcrum of bronchoscopic lever, posi- 
 tion of. 163, 265 
 Fulguration for papillomala of larynx, 
 
 424 
 Gag, use of. 69 
 mouth, 38 
 
 in bronchoscopy, 38, 162 
 Gallows for suspension laryngoscopy 
 
 136 
 Galvanocaustic treatment of tuber- 
 culosis, 116 
 Galvanocauterization for chronic hy- 
 pertrophic laryngeal stenosis. 115 
 of post-diptlieritic suligh)ltic 
 stenosis, effectiveness of. 115 
 Galvanocautery puncture, 116
 
 xu 
 
 INDEX. 
 
 Galvanocaustic deep puncture in 
 
 suspension laryngoscopy, 152 
 Galvanopuncture for laryngeal tuber- 
 culosis, 462. 
 Gangrene of lung. 484 
 
 bronchoscopy in, 248 
 Gastric mucosa, 193 
 Gastroscope. angular, 13 
 author's, 24, 577 
 Janeway, 577 
 Gastroscopical examination of a gas- 
 trojejunostomy wound, 575 
 Gastroscopy, 29, 568-578 
 anesthesia for, - 58, 65 
 cases of, 574-575 
 for foreign bodies, 576 
 lens-system, 577 
 mortality of, 570 
 open-tube, 577 
 outlining of stomach in, 571 
 position of patient for, 575 
 technic of, 570 
 
 through the celiotomic wound, 
 577 
 Gastrostomy in cases of water 
 hunger, 491 
 
 in hiatal esophagismus, 521 
 in malignant disease of the esoph- 
 agus, 445, 450 
 in stenotic esophageal disease, 491, 
 498 
 Gauging depth by use of one eye 
 
 only, 104 
 Gauze dressing in laryngostomy, 639 
 Globus hystericus, 508 
 Glottic chink, 188 
 
 phonation for identification of, 
 in direct laryngoscopy, 123 
 Glottis, exposure of, 98 
 
 loss of foreign body at, cause of, 
 
 274-275 
 opening of, in bronchoscopy, 162 
 Goiter as cause of congenital 
 tracheal stenosis. 470-471 
 dyspnea of, cane-shaped cannula 
 
 relieving, 590, 592 
 operations, examination of 
 
 larynx previous to, 91 
 Gown for operator. 46 
 Granulations, removal of. 301 
 Granuloma. 421 
 
 of tracliea. 433 
 Growths hidden by overhang of the 
 ventrioilar band, 109 
 
 in larynx, benign, 420-430 
 in ventricle of Morgani. schema 
 illu.strating lateral method of ex- 
 posing. 110 
 of trachea, malignant, bronchos- 
 copy in, 442-443 
 springing from the outermost 
 depth of the right ventricle, 
 109 
 
 Growths, laryngeal indirect views of 
 different types of, 104 
 on cords, 89 
 primary in tracheobronchial tree, 
 
 benign, 431-435 
 removal of, from laryngeal 
 
 ventricle, 109 
 sessile, removal of, 110 
 subglottic, removal of. 131 
 vascular, 60 
 Guillotine, Katzenstein, 420 
 Handle, author's universal, 33, 41 
 Handles tor laryngoscopes, bronch- 
 scopes, and esophagoscopes, Briin- 
 ings' two illuminating. 13, 14 
 Head, during bronchoscopy, position 
 of, 241, 257 
 
 position of, in direct laryngoscopy, 
 
 101 
 in peroral endoscopy, 85, 88 
 supporting-apparatus for, at- 
 tached to suspension appliance, 
 135 
 Head-cover, 46 
 Headlamp, Klrkstein, 12, 27, 28, 
 
 Kirstein, Killian's use of 142, 
 143. 145, 202, 264 
 Headlight. Claar, 15 
 
 as used bv Guisez, 202 
 Phillip, 16, 17. 21 
 Hemicricoarytenoidectomy in malig- 
 nant disease of larynx, 652 
 Hemilaryngectomy for malignant dis- 
 ease of larynx, 652 
 Hemophilia, 53, 118 
 Hemoptysis, bronchoscopy in, 466, 
 486 
 
 causes of 487 
 due to luetic lesions, 485 
 Homorrhage, laryngeal, in homophiles, 
 118 
 tuberculous pulmonary during 
 bronchoscopy, 262 
 clamps, 150, 152 
 Hemostat, 58 
 Heroin, 57 
 
 Hiatus, constricting musculature at, 
 drawing of under-surface of dia- 
 phragm showing. 512 
 Hiatal constricture. identification of. 
 191 
 esophagismus, 510-521 
 Hiatus, passing the, 190, 192, 193 
 Hook, curved, full 278, 286 
 Killian 40 
 Lister, 40, 272 
 
 Reichert. for pulling forward 
 
 base of tongue and larynx, 143 
 
 Reichert, for raising epiglottis, 
 
 140, 144 
 
 Hooks, 272 
 
 Hot-air-chest, Albrecht, for edema, 153
 
 INDUX. 
 
 iJydrogen peroxide after interven- 
 tions in laryngeal tuberculosis, 154 
 Hyoid bone, antagonism of muscles 
 attached to, 72 
 
 downward traction of tissues at- 
 tached to, 96, 98, 99 
 elevation, 64, 69, 71, 124 
 elevation of tissues attached to, 
 121 
 Hyperplasia. subglottic. following 
 
 diphtheria. 11.5 
 Hvperthymization of bleed 91, 473, 
 
 475 
 Hypodernioclysis, o'S 
 Hypoiiliaryngeal wall, mucosa from. 
 
 fAOUgiiig of. 196 
 Hypopharyngoscopy, 90, 181 
 Hypopharynx. exposure of. 181 
 
 livpopharvngoscopv for studv of. 
 9(1, 181 
 Hysteria, anesthesia in. 56 
 Hysteric, foreign bodies in the, 208 
 Illuminating devices, 11, 16 
 Illumination, defective, 202 
 
 distal versus proximal, 264 
 for suspension laryngoscopy, 142 
 Image, bronchoscopic, normal, 175 
 endoscopic, 92-95, 99, 118, 131, 
 
 176, 192. 341 
 sketching the. 204 
 Indirect views of different types of 
 
 laryngeal growths, 104 
 Infiltrations, diffuse laryngeal, 107- 
 108 
 
 direct laryngoscopy in treatment 
 of ulcerative and nonulcerated. 
 117 
 Influenzal tracheitis, 480-482. 484 
 Insane, foreign bodies in the, 208 
 Instructions to patients in endoscopy, 
 
 95-96 
 Instrumentarium, portable. 29 
 Instruments, author's, 16, 202 
 Briinings, 102, 201, 202 
 care of. 4S-.".l 
 for bronchoscopy. 85 
 diagnostic direct laryngoscopy in 
 
 children. 126 
 endoscopy arrangements of 44. 
 49 
 
 necessary, 47 
 for esophagoscopy, 85 
 for removal of papillomala in 
 
 larynx, 127 
 for suspension laryngoscopy, 13."i 
 Kahlcr's. 102. 201 
 iiKiti-rial for manufacture of. 11 
 modilicalions of. 11 
 sterilization of 47 
 Insufflation. .".9, 60, 61, 62. 64. 65 
 apparatus, Braun. 143 
 bronchoscopic oxygen. 73-76 
 
 Insufflation, ether. 38 
 
 anesthesia, Klsberg apparatus for, 
 61. 64, 73 
 Intercricothyroidotomy, 592 
 Intratracheal insufflation anesthesia, 
 65, 66-68, 73, 75, 320, 669 
 
 tubes, technic of insertion of, 68 
 oxygen insufflation, 75 
 laryngeal stenosis, 622-627 
 treatment of chronic laryngeal 
 stenosis, care of patients 
 under, 624 
 duration of, 627 
 vocal results of, 627 
 Introducer for author's self-retaining 
 intubation tubes, 626 
 Mosher, 626 
 Intubation and extubation, 624 
 
 in acute laryngeal stenosis, 583 
 of esophagus for stenosis, 539 
 of esophagus in malignant disease, 
 
 450 
 tracheal, 75 
 tubes and instruments, 622 
 
 care of, 625 
 tube for chronic laryngeal stenosis, 
 self-retaining, author's, 625, 626 
 tubes and chronic laryngeal 
 
 stenosis, sizes of, 625 
 tubes, esophageal, Charters Sy- 
 
 monds,' 451-452 
 tubes, self-retaining, Schmiegelow, 
 
 624 
 and extubation, 624 
 Intubational dilatation of chronic 
 laryngeal stenosis, 622-627 
 
 treatment of chronic laryngeal 
 stenosis, care of patients 
 under, 624 
 duration of, 627 
 vocal results of. 627 
 Iodine after interventions in laryn- 
 geal tuberculosis. 154 
 
 .laws lor author's forceps, side-curved, 
 
 34 
 Knife, galvanocautery, 115 
 
 laryngeal, author's, 112 
 Laboratory examinations ot secretions, 
 
 16 
 Lactic' acid after intervention for 
 
 laryngeal tuberculosis, 154 
 Lamps, bronchosco|)ic, 22, 23, 201 
 Uriinings, cleansing of, 28 
 cleansing of, 23 
 cold, 21 
 
 sterilization of, 47 
 Laryngeal acromegalic stenosis, trache- 
 otomy in, 587 
 cancer, operation for, mortality 
 and results of, 652
 
 XIV 
 
 INDEX. 
 
 Laryngeal, palliative treatment in, 647 
 prophylactic treatment in, 467 
 recurrence in, 655 
 site of, 651 
 statistics in, 657 
 complications of typhoid fever, 
 
 618 
 disease, endoscopic appearances of, 
 
 460 
 exposure tor intratracheal insuf- 
 flation, 75 
 exposure, left-handed. 103 
 exposure, prolonged, 103 
 
 laryngectomy for, mortality 
 
 in, 656 
 malignancy, excision of, 665 
 operation tor, choice of, 650 
 
 contraindications to, 649 
 statistics in, 657 
 mirror in suspension laryngos- 
 copy, 153 
 Killian method of using, 90-91 
 operation, direct, preparation of 
 patient for, 103 
 technic of, 103-107 
 orifice and swallowing, 236 
 papillomata (see papillomata) 
 
 in children, 149-151 
 paralysis, 205, 501 
 paralytic stenosis, bilateral, 613- 
 614 
 monolateral, 614 
 reflex, 60 
 sarcoma, 439-440 
 specimen for diagnosis, obtaining, 
 
 107 
 stenosis, acute, surgical treatment 
 of, 583 
 ankylotic, 615 
 acromegalic, tracheotomy in, 
 
 587 
 chronic, dilatation of, 622-627 
 preventing decannulation, 
 types of, 612-621 
 cicatricial, laryngostomv in, 
 631 
 post-diphtheritic, 618 
 complicating typhoid fever, 
 
 acute, 580 
 decannulation after cure of, 
 645-646 
 cork for occluding can- 
 nula before, 646 
 dilatation of, Thosfs appara- 
 tus for, 632 
 diphtheritic, 617 
 due to perichondritis, acute, 
 
 in infants, 583 
 in new-born, 582 
 intubation treatment for, care 
 
 of patients under, 624 
 luetic, 617 
 
 Laryngeal stenosis, neoplastic. 615 
 panic, 612 
 
 papillomatous. 615, 631 
 paralytic, cordectomy in, 613 
 
 treatment of, 614 
 post-tracheotomic, 593 
 scarlatinal, 619 
 schema of problem in, after 
 
 wearing of cannula, 630 
 scleromatous, 617 
 spasmodic, 613 
 
 treatment of, 613 
 suicide and, 620 
 tonsil in. removal of, 599 
 traumatic, 619 
 tuberculous, 616 
 typhoid, 618 
 stridor, congenital, 130, 462-464 
 surgery, 579-583 
 tumors above cords, removal of 
 
 benign, 110 
 web in child simulating neoplasm, 
 congenital. 129 
 Laryngectomy, 66 
 
 after-care following, 672 
 anesthesia in, 669 
 complications of, 673 
 contraindications to, 672 
 death in, causes of, 653 
 for malignant disease of larynx, 
 indications for, 652 
 mortality in, 656 
 glands during, removal of, 672 
 position of patient for, 669 
 preparation of patient for, 669 
 sphygomomanometric tracings dur- 
 ing, 653-654 
 stitching of trachea to skin in, 659 
 technic of, 669-673 
 operative, 669 
 total, operative mortality of. 653 
 tracheotomy preliminary to, 671 
 with intratracheal insufflation 
 anesthesia, schema of, 670 
 Laryngopharynx, familiarity with lo- 
 cation of, essential to esophagoscopy, 
 205 
 Laryngoptosis, tracheotomy in case of, 
 594 
 
 with deviation of trachea, 468-470 
 Laryngoscope, author's direct, 16, 20, 
 21 
 
 cleansing of, 100 
 
 during direct laryngoscopy, 
 107 
 Dickenson's. 19 
 direct for hyoid bone elevation, 64 
 
 stages in introduction of, 121 
 Hill's modification of Jackson, IS 
 introduction of, 58, 76, 92, 96-98, 
 
 101 
 L-shaped, 102
 
 INDEX. 
 
 XV 
 
 Laryngoscope, narrow lube, 102 
 oval lumen, 17, 19, 20 
 regular, for introduction of bron- 
 
 <hos<'ope, 157 
 round lumen, 17, 20 
 side-opening, 72 
 side-slide, 110 
 subglottic, 25, 26 
 Laryngoscopes, 16, 19, 20, 25, 26, 75 
 
 direct, 90, 95 
 Laryngoscopic tube, introduction of, 
 
 by Briinings' method, 17;i 
 Laryngoscopic views in children, di- 
 rect, 129. 130 
 Laryngoscopy, differenie in viewpoints 
 in direct and indirect, S9-90 
 
 direct, 52, :,:!, 62, 72, 7S, SI, 82, 
 85, 86, 89-132 
 anesthesia for, 55, 59, 64 
 by lateral and oblique meth- 
 ods, 101 
 contraindications to, 92 
 difficulties of, 100, 123 
 endoscopic view at end of sec- 
 ond stage of, 123 
 for the removal of foreign 
 
 liodieK, 266, 269 
 in adult recumbent patient, 
 
 118-126 
 in children, 126, 128 
 
 compared to that in 
 
 adults, 127 
 difficulties of, 127 
 in diseases of the larynx, 460- 
 
 464 
 instruments for diagnostic, 
 
 126 
 instructions to patients in, 95- 
 
 96 
 jiosition for, 83, 84, 85 
 rules for, 100 
 schema illustrating technic of, 
 
 122 
 sijeculum in, 20, 28 
 view at end of first stage of, 
 121 
 indirect, 89-91 
 
 with the Hays' pharyngo- 
 scope, 131 
 post-anesthetic, 67 
 subglottic, 102 
 
 in children, 130 
 suspension, 126, 133-154 
 anesthesia for, 134, 142 
 as a preliminary step to 
 bronchoscopy and esoph- 
 agoscopy, 147 
 clinical experiences with, 146 
 demonstration in, 146 
 examination with Kirsteln 
 spatula preliminary to, 142 
 for diagnostic purposes, 151 
 
 Laryngoscopy, suspension, removal ot 
 foreign bodies, 154 
 
 treating lower pharvnx, 
 
 154 
 removal of metallic cap- 
 sule from right bron- 
 chus, 148 
 removal of nail lodged 
 one year in left bron- 
 chus, 148 
 removal of nodules on 
 
 vocal cords, 151 
 removal of papillomata, 
 151 
 historical data on, 133 
 in adults, 152 
 
 in children, therapeutic appli- 
 cation of, 148 
 instruments for, 135 
 in tonsillectomy, 151 
 in tuberculosis of larynx, 152 
 origin of, 133 
 
 preparation of patient for, 142 
 removal of foreign bodies 
 under, 148 
 
 Laryngostomy, 628-644 
 
 after-care following, b,;9 
 
 after-treatment of, Sargnon's 
 method of, 630 
 
 ajiparatus in situ, author's radio- 
 grapihc view of, 638 
 
 author's method of, schema of, 630 
 
 autopla^ity after, 642 
 
 lacing adhesive strips for 
 lessening tension on sutures 
 in, 644 
 
 contraindications to, 632 
 
 definition of, 628 
 
 dilating tube and dressing in, plac- 
 ing of, 635-636 
 
 epidermatization in author's meth- 
 od of hastening. 6111-642 
 
 for laryngotracheal stenosis, 643 
 papillomata ot larynx, 427 
 
 history of, <)28 
 
 llowarth method of, 629, 631 
 
 indications for, 631 
 
 incision of posterior wall in, 635 
 
 in post-typhoid laryngeal stenosis, 
 results in, 644 
 
 instruments for, 632 
 
 one month after 0|)eration, 637 
 
 prcliiiiiiKii'ies for, 633 
 
 prc|iaration of i)atient for, 633 
 
 result in, ideal, 641 
 
 rubber tube, .Moure. 632 
 
 steps in, 634 
 
 suture of mucosa to skin in. 637 
 
 treatment, duration of, 642 
 
 wound iuimediately after, 636 
 
 l.aryngotomy. 634
 
 XVI 
 
 INDEX. 
 
 Larynx, anesthesia in paralysis of, 64, 
 72 
 appearance of, in direct laryngos- 
 copy by the oblique method, 102 
 artififial, 673 
 bone in entrance to, removed by 
 
 suspension laryngoscopy, 148 
 cancer of, palliative treatment in, 
 647 
 prophylactic treatment in, 647 
 child's, endoscopic appearance of, 
 
 128 
 cocain for penciling, 143 
 depth of, misconception of real, 
 
 104, 105 
 difficulty of finding, 100 
 diseases of, direct laryngoscopy 
 in, 460-464 
 tracheotomy as a therapeutic 
 measure in, 584 
 during bronchoscopy, position of. 
 
 163 
 edema of, 580 
 
 endoscopic evisceration of, for ci- 
 catricial stenosis, 113 
 examination of, for diagnosis. 70, 
 78, 92 
 previous to anesthetization. 
 
 91 
 with Hays pharyngoscope, 132 
 exposure of, 70, 71, 72, 76, 82, 84, 
 86. 88, 94, 96, 98-102. 106, 118 
 difficulty in, 163 
 for radium application, 103 
 recumbent patient. 158 
 stage in. 121 
 foreign liody in. 92 
 granulation tissue in the, 269 
 granuloma in, 420 
 growths in, benign, 420-430 
 inspection of, previous to inser- 
 tion of catheter or tubes, 68, 69, 
 75 
 in typhoid fever, acute stenosis of, 
 
 581 
 malignant disease of, 647-660 
 curative operations for, 649 
 endoscopy in, 437, 441, 649 
 operation in. 649 
 thyrotomy for, 661-668 
 obstruction in, 59, 75 
 opening of. error in, 635 
 overflow of secretions into, 79 
 papillomata of, in adults, 427-430 
 
 in children, 422-427 
 paralysis of, 91 
 
 removal of foreign bodies from, 
 55, 88 
 growths from, 78 
 spasm of, 99, 105, 128 
 stenosis of. acute. 92, 580-583 
 tuberculosis of, 460 
 
 Larynx, tuberculous, direct view in 
 sitting position of a, 116 
 lesions below, 117 
 Left hand, advantages of holding bron- 
 choscope in, 166 
 Left-handed laryngeal exposure, 103, 
 
 121 
 Leucoplakia, an early stage ot esopha- 
 geal cancer, 448 
 Light carriers, 19, 21, 23 
 Lights, care of, 51 
 Lii)oma in hvpopharvnx, removal of, 
 
 154 
 Lip, pinching of, between instrument 
 
 and teeth. 101 
 Ludwig's angina, foreign bod.v simulat- 
 ing, 338 
 Lues, 107, 108 
 
 cancer of stomach simulating, 448 
 of esophagus, 561 
 of tracheobronchial tree, 485 
 Lumen, laryngeal, 68, 69, 93 
 Lung, gangrene of, 484 
 
 gangrene of, due to presence of 
 foreign body, 320 
 Malignancy, esophageal. 193 
 Malignant diseases of larynx, 647-660 
 Mandrin, 14, 15. 23, 24, 187, 197, 219 
 in exploring esophagus for for- 
 eign bodies, 342 
 Mask for operator, 46 
 Jlasks in artificial respiration, 75 
 Measuring rule, 25 
 Mediastinitis. fatal septic, due to 
 
 faulty esophagoscopy, 196 
 Mesothorium treatment of laryngeal 
 carcinoma, 154 
 to prevent rec\irrence of laryngeal 
 papillomata, 149 
 Morphin, 56, 63, 118 
 
 in suspension laryngoscopy, use of, 
 142. 152 
 Morphin-scopolamin, contraindications 
 
 to use of, 143 
 Nebulized fluids in treatment of dis- 
 ease, inhalation of, 467 
 Neoplasms, change of connective tissue 
 type of. to epithelial type, 439-441 
 esophageal, benign, 436 
 laryngeal, 62 
 Nephritis, preparation of, for endo- 
 
 laryngeal operation, 53 
 Nodules on vocal cords, 151, 420 
 Nozzle for aspirator for removing se- 
 cretions from fauces and pharynx, 29 
 Xurse, tracheal, after endolaryngeai 
 
 operation, 117 
 Obturators. 24 
 Operating room, 43 
 organization, 579
 
 INDEX. 
 
 XVll 
 
 Oiiiuni dirivalives, loxio effect of, 62, 
 
 125 
 Orientation in direct laryngoscopy, 101 
 Oropharynx, interventions in. 1.")1 
 Ortlioform in bronchial asthma, ITlt 
 Osteomata of trachea, 4oo 
 Oxygen, jti. 'i'.). To, 7t, T-J 
 
 insufflation, branch tube for bron- 
 
 choscopic, 22 
 tank, 4."), 50 
 Packing of tracheal and external 
 laryngeal wounds, author's method 
 of, "639 
 Panelectroscope, Kahler's, 17 
 Papilloma, 55, 57, 58, 59, 62, 87, 92, 9:i, 
 112 
 
 laryngeal, congenital, 422 
 Papillomata, fibro-, multiple infraglot- 
 tic, 104 
 
 foreign bodies mistaken for, 267 
 in children, author's method of 
 treating, 426 
 
 treatment of, 422-427 
 in hyi)o-|)liarynx and esophageal 
 
 entrance, removal of, 151 
 larvngeal, in adults, 427-4:50 
 
 in children. 149-151, 422-427 
 instruments tor removal of, 
 
 127 
 suspension laryngoscopy for 
 removal of, 151 
 multiple, 104 
 of the larynx in adults, stuliljoin 
 
 case of, 104, 428 
 primary in trachea, 431 
 recurrence of. 149 
 removal of, depth of, 427 
 stenoses due to, 631 
 subglottic. 130 
 tracheal. 609 
 Paralysis, esophageal, 557-561 
 laryngeal, 205, 501 
 
 nerve-division in l)iUitcral, t')l3 
 posticus, 113, 196 
 recurrent, 196, 466 
 Perichondritis in infants, stenotic 
 laryngeal. 5S3 
 
 laryngeal, tracheotomy in post- 
 tyiilioid, 599 
 Peroral endoscopy, position of patient 
 for. 77-88 
 
 preparation of patient for, 53 
 Personal e(iuati()n in clioice of anes- 
 thesia, 54 
 Pharyngotomy, subhyoid, for malig- 
 nant disease of larynx, 652 
 Pharyngosco|)e, Hays, for examination 
 of larynx, 132 
 
 indirect laryngoscopy witli. 
 131 
 Pharynx, bone in, removed by suspen- 
 sion laryngoscopy, 148 
 
 Pharynx, safety pin in, removed by 
 suspension laryngoscopy, 148 
 
 suspension laryngos<-oiiy for treat- 
 ing lower, 154 
 Phonation. 114 
 
 continuous, for identification of 
 glottic chink and vocal cords, 
 123 
 Phrenospasm, 510-521 
 Pin-closer, 285, 286 
 
 Plastic operation favoring develop- 
 ment of adventitious vocal bands. 
 429-430 
 Pleura, perforation of, due to faulty 
 
 esophagoscopy, 1 96 
 Pleurisy, foreign body simulating, 300 
 Pleuroscope, 25 
 
 Pleuroscopy for ideural diseases, 364 
 for removal of foreign bodies, 321, 
 363 
 Pneumonia, bronchoscopy during, 248 
 Pneumonitis following aspiration of 
 
 foreign body, 299, 311 
 Pneumothorax, bronchi in, 487 
 
 displacement of foreign body 
 after, 325 
 Polypi in tracheobronchial tree, ede- 
 matous, 435 
 Polypus, removal of, demonstrated by 
 suspension laryngoscopy, 146, 154 
 of vocal cords, 154 
 Position, Bovce. 70, 83, 84, S6, 119, 157. 
 164, 188, 326 
 advantages of. for esophagoscopy, 
 190 
 wide range of, 258 
 elbow-rest, author's, 70, 125 
 extended, 70, 71, 79-81 
 Hexed, 85 
 for bronchoscopy, 83 
 
 direct laryngoscopy, 82, 83 
 
 author's, 82 
 esophagoscopy, 83 
 
 author's "high-low," 79 
 .lohnston, 85, 86 
 Kirstein. 79, 81, 82 
 Mouret, 82, 83 
 
 of adult patient for direct laryn- 
 goscoi)y. sitting. SI, 84 
 assistant for bronchoscopy, 167 
 for direct laryngoscoi)y, 82, 84 
 cervical si>ine for eso|)bagos- 
 copy and bronchoscopy, cor- 
 rect, 80, 81 
 infant or small child during 
 
 direct laryngoscopy, 128 
 operator, for artilicial respira- 
 tion, 74 
 for direct laryngoscopy, 
 82, 84, 9G, 97
 
 -Will 
 
 INDEX. 
 
 Position of patient and assistants for 
 tracheotomy and for artificial res- 
 piration, 595 
 
 patient for bronchoscopy, 86, 
 155, 466 
 for esophagoscopy. 86, 492 
 for insufflation anesthesia, 
 
 69, 70 
 for gastroscopy, 575 
 for laryngectomy, 669 
 for laryngostomy, 633 
 for peroral endoscopy, 77- 
 
 88 
 for radium applications to 
 esophagus, 456 
 table for suspension laryngos- 
 copy, 135-137 
 recumbent, 83-88, 115, 118, 122, 
 
 127. 157 
 dorsally, 183 
 
 for bronchoscopy in children, 
 172 
 removal of foreign bodies, 
 
 235 
 specular esophagoscopy, 
 185 
 lateral, 164 
 
 sitting or laterally, 184 
 ventral, for introducing bron- 
 choscope, 174 
 Rose. 79. SO, 119, 202 
 
 in l)ronchoscopy, 264 
 
 esophagoscopy, 181, 190 
 Positions, general principles for all, 
 
 79 
 Position, sitting, 88, 92, 96. 101, 102, 
 116, 127, 155 
 Trendelenberg, 66, 78 
 
 during tracheotomy, 287 
 Potassium iodid, 108 
 
 and mercury in compression 
 
 stenosis of esophagus, 501 
 to prevent recurrence of laryngeal 
 papillomata, 149 
 Practice, thread, with bronchoscope 
 
 and forceps, 202 
 Preparation of patient for i)eroral en- 
 doscopy, 53 
 Probe for endoscopic use, eyed, au- 
 thor's, 43 
 radiographic localization, lead- 
 ended, Briinings, 296 
 Propaesin in bronchial asthma, 479 
 Proximal illumination, 27 
 Pulmonary abscess, bronchoscopy dur- 
 ing, 248, 476 
 Pulmotor, 75 
 
 Puncture, galvanocautery, 116 
 Pus, removal of, before bronchoscopy, 
 
 301 
 Pyopneumothorax of foreign body ori- 
 gin, 311 
 
 Pyriform sinus, accidental exposure 
 of, 100 
 
 entering, 188 
 
 familiarity with location of, es^ 
 
 sential to esophagoscopy, 205 
 finding of, 88, 189 
 in esophageal stenosis, 491, 500 
 right, 188 
 Radiography in diagnosis of esopha- 
 geal diseases, 489 
 
 in diagnosis of esophageal diver- 
 ticulum. 545 
 thoracic disease, 301 
 foreign body work, 209-212. 219- 
 
 234, 301, 403-417 
 negative, value of, 231 
 Radium application to cancer of 
 cardia, peroral, 459 
 
 capsule in center of annular 
 esophageal cancer, sche- 
 matic representation of, 454 
 situ in case of esophageal 
 cancer, 457 
 container in situ in case of esoph- 
 ageal malignancy, 457-459 
 for malignant disease of esopha- 
 gus, 452-459 
 author's method of using, 454 
 dosage of, 456 
 reaction after, 458 
 
 of larynx, 439, 455 
 for papillomata of larynx, 424 
 Ratchet, 14. 174 
 
 Rectal feeding in cases of water hun- 
 ger, 491 
 Reflector, Claar, 12 
 Reflexes, abolition of, 94 
 
 protective, 236 
 Respiration, arrested, 59, 60, 67, 74, 75, 
 76 
 artificial, position of patient and 
 
 assistants for, 595 
 arrested, tracheotomy for, 584 
 Roentgen ray treatment of laryngeal 
 tuberculosis in suspension laryngos- 
 copy, 154 
 Salicyl-alcohol to prevent recurrence 
 
 of papillomata. 149 
 Saliva during direct laryngoscopy, 101 
 Sarcoma, esophageal, 449 
 
 laryngeal, 107, 439-440, 651 
 Scleroma, suspension laryngoscopy in, 
 
 154 
 Scoijolamine in suspension laryngos- 
 copy, 142, 152 
 
 Secretions, 71, 79 
 
 age on removal of, influence of, 
 
 482 
 drowning of patient in his own, 
 
 262, 280, 482-484 
 during esophagoscopy, 79 
 laryngoscopy, 127
 
 INDEX. 
 
 Secretions, in foreign body cases, 234 
 lessening of, during bronchoscopy, 
 
 63, 78 
 nozzle for attaching to aspirator 
 for freeing fauces and pharynx 
 from, in peroral endoscopy, 29 
 prevention of, overflowing from 
 
 pharynx into larynx, 30 
 removal of, 21, 23, 29, 30, 31, 77- 
 7S, 483-484 
 during l)ronchoscopy, 4(56 
 during direct !aryngoscoi)y,106 
 in esophagoscopy, 194 
 prior to insertion of broncho- 
 scoi)e, 1(13 
 sponge-pumping process for re- 
 moval of, author's (see sponge- 
 pumping process) 
 Yankauer's method of removing, 
 28 
 Shield for gallows to prevent patient 
 coughing in oi)erator's face, 147, 152 
 Sinus, pyriforni, 188 
 Sketching the endoscopic image, 204 
 Skill, acquiring for peroral endoscopy, 
 
 199-205 
 Slide, author's, 17, 18, 19 
 Sliding tubes, Hriinings, 12, 17 
 Snare, bronchoscoiiic, 39, 4(1 
 
 cannula, heavy, 39, 40, 110, 112, 421 
 eso|)hagoscopic, 39 
 galvanocautery, 110 
 tonsil, Peter's, 39, 40 
 Solutions in treatment of bronchial 
 
 asthma, 479-480 
 Spasm, 75, 70, 93, 94 
 
 esophageal, in new-born, 507 
 
 secondary to local disease, 'MG 
 hiatal, overcoming of, 194 
 hypopharyng(^al, liO 
 laryngeal. occluding view of 
 
 larynx, 123 
 of esophageal musculature, fiO, 61, 
 65 
 inferior constrictor, 65 
 Spasmodic contractions in esophagos- 
 copy, 194 
 
 stenosis of esophagus at crico- 
 pharyngeal level, treatment of, 
 510 
 Spatula, Briinings, 14 
 
 epiglottis, use of, 145 
 Kirstein, 133, 142, 144 
 tongue, 137, 140, 144 
 
 introduction of, 144 
 with dental protector, Mosher's 
 laryngeal, 19 
 Specimen for diagnosis, laryngeal, tak- 
 ing a, 107 
 
 malignant, necessity of Immediate 
 oi)eration following removal of. 
 108 
 
 Spectacles, 40, 42, 46 
 Speculum, Boyce, 16 
 Dickinson, 19 
 
 esophageal, anesthesia for use of 
 the, 65 
 author's, 25, 26, 32, 64, S8, 181, 
 
 185, 492 
 in foreign body work, 344-346 
 introduction of, 186, 345 
 use of child's size of, for sub- 
 glottic laryngoscopy, 102 
 exposure of larynx with, 96 
 Ingal's open laryngeal, 12 
 introduction of, for removal of 
 
 small tumor on cords, 106 
 author's laryngeal, 16 
 laryngeal, 15, 16, 20, 64, 69, 71, 
 for inspection of hypopharynx 
 and cricopharyngeal con- 
 striction, 185 
 insertion of, 71, 72 
 Rendu, for gastroscopy through 
 
 celiotomic wound, 577 
 rotating, laterally, 85 
 sizes of, 20, 26 
 slide, 16 
 
 tubular, author's, 18 
 use of lateral opening, 102 
 with laryngoscope handle, John- 
 ston's, 18 
 Sphygomomanoraetric tracings dur- 
 ing laryngectomy, 653-654 
 Spine, position in diseases of cervical, 
 
 85, 86 
 Sponge-carrier, author's, 30, 31 
 
 Coolidge, 30 
 Sponge-holder, 58 
 Sponge-pum|)ing process, author's, 163, 
 
 194, 262, 275, 291, 301, 304, 308 
 Sponges, 23, 31, 32, 58 
 bronchoscopic 32, 58 
 endoscopic, 31, 32 
 use of, during bronchoscopy, 163 
 Sponging in foreign body work, 342 
 Spoon, mechanical, author's, 39, 292 
 Status lymphaticus, 473 
 bronchoscopy in, 248 
 Spasmodic stenosis of the esophagus, 
 
 504-521 
 Stenosis at cricopnaryngeus, esopha- 
 goscopic appearances of spasmodic. 
 509 
 abscesses and, 620 
 ankylotic, post-ty|)hoid, (!19 
 bronchial, cicatricial, 477 
 cicatricial, laryngoslomy for, 631 
 treatment of, 621-627 
 compression, depth of, 472 
 esophageal, 496 ( see stenosis of 
 
 esophagus) 
 in new-born, laiyngeal, 582
 
 INDEX. 
 
 Stenosis, laryngeal, ankylotic, 615 
 
 decannulation after cure of, 
 
 645-646 
 dilatation of, 622-627 
 diphtheritic, 617 
 evisceration of larynx for ci- 
 catricial, 113 
 g a 1 V a n o cauterization for 
 
 chronic, 115 
 intubation for, 624 
 luetic, 617 
 neoplastic. 615 
 panic, 612 
 
 papillomatous. 615, 631 
 paralytic, 613 
 removal of tonsils in patients 
 
 with, 65 
 scarlatinal, 619 
 schema of problem in, 630 
 scleromatous, 617 
 spasmodic, 613 
 suicide and, 620 
 surgical treatment of acute, 
 
 583 
 tuberculous, 616 
 Stenoses, laryngeal, typhoid, 618 
 of esophagus, cancerous, 528 
 cicatricial, 522-539 
 and cancer, 529 
 due to presence of foreign 
 
 body, 524 
 etiology of, 522 
 radiograph showing cure 
 
 of a, 534 
 spasmodic lesions caus- 
 ing, 523 
 symptoms of, 526 
 treatment of, 530 
 compression, 499-503 
 adenopathic, 501 
 aneurysmal, 500 
 aortic, 500 
 
 carcinomatous and sarco- 
 matous, 501 
 differential diagnosis of, 
 
 499 
 goitrous, 500 
 treatment of, 501 
 
 differential diagnosis in, 528- 
 
 530 
 luetic. 562 
 spasmodic, 504-521 
 
 due to aphthous ulcera- 
 tion, 496 
 reflex nature of, 505 
 of larynx, acute, 580-583 (see 
 laryngeal stenosis) 
 and trachea, chronic, 612-621 
 of trachea, compression, 615 
 
 and bronchi, compression, 47u- 
 476 
 
 Stenoses, treatment of, 472 
 post-diphtheritic, 113 
 
 sub-glottic, galvano-cauterlza- 
 tion of, 115 
 preventing decannulation, hyper- 
 
 lilastic and cicatricial, 616 
 thymic compression, 131, 472-476 
 tracheotomic, post, 593 
 traumatic cicatricial, 619 
 Stimulants, 63, 74 
 
 Stomach, .vlosher's device for balloon- 
 ing the, 24 
 Stools, tor operating, 85, 86, 96 
 Strictures (also see stenosis) 
 
 anesthesia in after-treatment of, 
 
 56 
 bougie for, author's modification 
 
 of Guisez', 44 
 bronchial, dilator for, 41 
 author's. 44 
 of esophagus, 521 
 cicatricial, prognosis of, 525 
 congenital, 493, 494 
 Stridor, congenital laryngeal, 462-464 
 due to infantile type of larynx, 
 
 463 
 serraticus, 609 
 String swallowing in esophageal 
 
 stenosis, 537 
 Styptics, 118 
 
 Subglottic hypertrophic post-diphther- 
 itic stenosis, 618 
 papillomata, 130 
 
 space, flat bone In, removed by 
 suspension laryngoscopy, 148 
 Suicide and stenosis, attempted, 620 
 Suiiraglottic hypertrophic post-diph- 
 theritic stenosis, 61S 
 
 tracheoscopy and subglottic laryn- 
 goscopy in children, 130 
 Sus]jension-hook for suspension laryn- 
 goscopy, 136 
 
 preparation of, 144 
 Suspension laryngoscopy (see laryn- 
 goscopy ) 
 Swallowing, mechanics of closing air 
 passages to food during, 111 
 normal, bismuth radiograph illus- 
 trating, 543 
 Syncope, 118 
 
 Synthetic compounds, 56 
 Syphilitic strictures, intubation in, 477 
 Syi)hlloma of trachea simulating 
 
 tumor, 434 
 Syringe, endoscopic, for injections, 41 
 
 468 
 Tables. 42, 85 
 
 dropping of, 122 
 
 for suspension laryngoscopy in 
 high position, 137 
 in ordinary position, 136
 
 INDEX. 
 
 Tables, oiJeiating. for suspension laryn- 
 goscopy, 13.') 
 
 French. 43, i'>, 120 
 Table-screws by which changes of posi- 
 tion are made. 138 
 Tests, liietin, 107 
 
 Wasserniann, 107 
 Thoracic operature, upper, 164, IG.'j, 
 171 
 
 disease, bronchoscopy in, 4GG 
 Thoracotomy. 73. 242, 320-321, 326 
 Thymic compression stenosis, 47 2-476 
 Thymopoxy. 47.'>-476 
 Thymus death, mechanical nature of, 
 
 4"73 
 Thyroid cartilage, backward pressure 
 of, for exposure of anterior commis- 
 sure, 106. 124 
 
 forward pulling of. lOii 
 tumors, benign. 433 
 Thyrotomic cases, after-care of, 667 
 Thyrotomy, 6.5, 66, 93 
 
 for cancer, operative technic of. 
 663 
 malignant disease of larynx. 
 6.50, 655 
 comiilications in, 668 
 dressings after, 666 
 indications for, 651 
 preparation of patient for, 
 
 661 
 technic of. 661-668 
 
 modification in, 668 
 statistic in, 655-657 
 liapilloniata of larynx, 424 
 or laryngofissurc, illustration of, 
 664 
 Tongue-spatula, 137, 140, 144 
 
 introduction of, 144 
 Tonsillectomy under suspension laryn- 
 goscopy, 151 
 Tonsils, removal of. in cases of laryn- 
 geal stenosis, 5!iy 
 
 removal of, in patient with laryn- 
 geal stenosis. 65 
 bronchoscopy in malignant 
 
 growths of. 442-443 
 deviation of. 470 
 
 diseases of. bronclioscopy in, 465. 
 diverticula of. 169 
 exploration of. 163 
 faulty incisions of, 597 
 growths of, diagnosis of malig- 
 nant, 442-443 
 growth of, treatment of, malig- 
 nant, 443 
 incisions of, 600 
 
 normal position of. 79. 81, 160, 185 
 relative position of esophagus and, 
 
 79 
 rules to be observed in passing 
 down, 166 
 
 Trachea, rupture of. subcutaneous, 586 
 stenosis of, 24S 
 
 compression, 470-476, 615 
 Trachea and laryngoptosis, deviation 
 
 of, 46S-470 
 Ti-eacheal blast. 162 
 
 incision, dangers in, 600-601 
 
 depth of, 600 
 intubation, 75 
 pressure, 53 
 
 rings, obliteration of, 161, 177 
 wall, endoscopic appearance of, 
 177 
 Tracheitis, influenzal, 480-482, 484 
 
 subglottic, edema following, 116 
 Tracheobronchial tree, anomalies of, 
 468 
 
 benign growth primary in. 431-435 
 lues of. 485 
 
 positive lilm of, 227, 229 
 Tracheobronchial tree, tuberculosis of, 
 
 bronchoscopy in, 485 
 Tracheobronchitis, circumscribed, 476 
 Tracheobronchoscopy, anesthesia in, 58 
 Tracheodernial fistula, autoplastic op- 
 eration to close, Berger, 642 
 Gluck, 642 
 Tracheoesophageal fistula, congenital. 
 
 493 
 Tracheoscopy, supraglottic in children, 
 
 130 
 Tracheotomic cannula, 589-590 
 
 attachment of tapes to, 608-609 
 laryngeal stenosis, post, 593 
 oi)ening. position of second, 594 
 Tracheotomizcd patient, anesthetizing 
 
 a, 65, 72 
 Tracheotomy, 56, 64, 67, 74. 75, 77, 
 92, 104, 112. 115. 116. 473. 584-611 
 after-care following, 606-611 
 anesthesia for, 596 
 as a therapeutic measure, 584 
 asejisis in, 595 
 compUcations after. 610 
 contraindications to, 5S7 
 decannulation after, 610 
 diet after, 606 
 dressings after. 607 
 during endolaryngeal oiieration. 
 
 118, 127 
 emergency, 602, 
 in dark, 605 
 rules for, 606 
 for compression stenosis of 
 trachea, 472 
 extubation in spasmodic cases, 
 
 613 
 foreign bodies. 584 
 malignant growths of trachea, 
 413
 
 IXDKX. 
 
 Tracheotomy tor papillomata of 
 larynx, 423 
 
 respiratory arrest, 584 
 subglottic edema, 265 
 hemorrhage after, 611 
 high versus low, 592 
 in acute laryngeal stenosis, 583 
 angioneurotic edema of larynx, 
 586 
 indications for, 384-587 
 in foreign body work, 215, 287 
 laryngeal hemorrhage in 
 hemophiles, 118 
 instruments for, 45, 588-589 
 mortality of, 587 
 nurse for, special, 607 
 position of patient and assistants 
 
 for, 595 
 preceding use of galvanocautery 
 
 in larynx, necessity for, 117 
 preliminary to laryngectomy, 671 
 preparation of patient for, 595 
 prevention of, in laryngeal tuber- 
 culosis, 154 
 prior to diagnosis, 594 
 rapid, author's method of, 603-605 
 sinking of patient after, 610 
 technic of, 599 
 tray, contents of, 609 
 Trauma, 55, 86 
 
 during removal of large, sharp 
 
 body, 179 
 laryngeal, 105, 265 
 rupture of trachea from external, 
 subcutaneous, 586 
 Traumatic cicatricial stenosis, 619 
 Tube, insufflation, size of, 68 
 intratracheal, 75 
 
 T-shaped soft rubber, Killian, 628- 
 629 
 Tuberculosis, galvanocaustic, treat- 
 ment of, 116, 205 
 
 laryngeal, 107, 116, 205, 460 
 
 author's endoscopic treatment 
 
 of, 116 
 Roentgen ray in, 154 
 suspension laryngoscopy in, 
 152 
 laryngoscoiiy in high dorsal, 85 
 of esophagus, 563 
 
 tracheobronchial tree, bron- 
 choscopy in, 485 
 pulmonary, 53, 234, 248, 300 
 advanced, 117 
 
 as a contraindication to re- 
 moval of foreign body, 262 
 foreign body simulating, 306 
 symptoms in, absence of, 486 
 Tuberculous laryngeal lesions, extir- 
 pation of, 461 
 stenosis, 616 
 
 lesions, direct laryngoscopy in the 
 local treatment of, 117 
 
 Tuberculous laryngeal lesions below 
 larynx, galvanocautery in, 117 
 
 perichondritis, foreign body simu- 
 lating, 268 
 Tubes, 11, 18, 19, 21, 22, 25, 256 
 Briinings, 12-14 
 
 preparation of, 197 
 conical ended, 303 
 screw-post, 623 
 esophagoscopic, sizes of, 194 
 intubation. 622 
 
 self-retaining dilating, in situ, 
 623 
 technic of insertion of intra- 
 tracheal insuiiiation, 68, 70 
 work, anesthesia in, 54 
 Tube-spatula, Yankauer's laryngeal, 16 
 Tumors above cords, benign laryngeal, 
 removal of, 110 
 
 below cords, removal of, 106 
 large laryngeal, schema illustrat- 
 ing removal of, by ex-tubal 
 method. 111 
 laryngeal, removal of, 107 
 on cords, removal of small, 106 
 removal of, by oblique method, 102 
 tracheal, benign, symptoms of, 434 
 Turbinotome for thyrotomy and laryn- 
 
 gotomy, author's, 633, 634 
 Typhoid fever, laryngeal complica- 
 tions in, 618 
 
 laryngeal stenosis complicating, 
 acute, 580 
 Ulcerated forms of esophageal malig- 
 nancy, 447 
 Ulcer of esophagus, differential diag- 
 nosis of, 496-498 
 Vagus reflex, 60, 103 
 Vagus-reflexes, cocainization of larynx 
 
 to overcome, 148 
 Ventricle, inspection of, 102 
 
 laryngeal, removal of growths 
 from the, 109 
 Ventricular bands, 60, 188, 236 
 
 accidental removal of, 104, 105 
 spasmodic closure of, hiding of 
 end of forceps by, 105 
 Vision, field of, 94, 95 
 Vocal impairment due to laryngeal 
 trauma, 105 
 nodules, 420 
 
 sessile, galvanocautery point 
 for removal of, 420 
 results after endoscopic eviscera- 
 tion of larynx, 113, 114 
 after operation for laryngeal 
 malignancy, 658-660 
 Voice, buccal, 113 
 
 in cases of larynegal stenosis, 114 
 Vomiturition, 54, 57, 72 
 Water hunger and esophagoscopy, 53, 
 491, 530
 
 INDEX. 
 
 XXIU 
 
 Webs in upper third of esophagus, 494 
 of larynx, congenital, 464 
 
 Window-iilug for occluding the prox- 
 imal tube-mouth when it is desired 
 to l)alloon esophagus or stomach, 
 Mosher's, 24 
 
 Abhk, 424 
 
 AliLK ( Wii.liamixa), 512 
 
 Adams (James), 480 
 
 ADI.KMAX. 332 
 
 ALriHKCiiT, 135, 136, 137, 141, 149, 151, 
 
 153, 420 
 AuitowsMiTH, 337, 565 
 Aver, 65, 73, 320 
 Bau.enger. 423 
 Bak (Loris), 116 
 BAitATorx, 628 
 BarlatikI!. 628, 635, 639 
 Barndouar. (W. p.), 66 
 Bakwell, 655 
 
 Bassler (Anthonv), 501, 506 
 Beck. 131, 290 
 Berger, 642 
 BOET.TER, 222 
 BOGGS, 219. 222 
 BowEX, 219 
 BoYCii 16, 38, 39, 70, 83, 86, 119, 164, 
 
 185, 188, 190, 219, 224. 231, 234, 258, 
 
 300. 302, 307, 308, 312, 470, 481, 483, 
 
 484, 500, 544, 653 
 Brain, 143 
 Brieger. 135. 154 
 BRfix, 525 
 BRrEXiNG.s, 12. 13. 14, 17, 28, 36, 55, 
 
 57, 102, 103, 141, 172, 174, 195, 197, 
 
 198, 201, 202, 231, 246, 263, 264, 271, 
 
 275, 296, 303, 304, 519, 539 
 Bryax, 91, 581 
 BrcilAXAX. 22, 59, 68, 484 
 BuTi.ix, 437, 650, 655 
 Cagxola, 628 
 Canai'EL, 628 
 
 Cari'Exter (K. W.), 238, 332, 484 
 Cakrel. 65 
 Cas.sadiax, 219 
 Cassei.rerry, 36, 56, 279 
 Chiari, 13.5, 332 
 Cr.AAU. 107, 202 
 
 Cr,ARK. 26, 248, 309, 319, 320, 475 
 Clayton, 319 
 Cohen (J. Sous), 659 
 Coi.E (L. G.), 219, 222 
 Cooi.iDGE, 30, 56, 324, 608 
 CoTTox. 65 
 Crii.e, 73, 5.50 
 CiT.nERT, 424 
 Ctneo. 651 
 Cthtis, 91 
 
 Da Cosia (.John C), 337 
 Davis, 64, 135, 247, 255, 461 
 
 65, 66, 69, 73, 320, 
 
 467, 476, 478-480, 484, 
 
 547, 552-555 
 
 673 
 467 
 
 Dei-avax. 91, 238, 319, 320, 423, 426, 
 
 439, 465, 622, 653 
 De Saxti 590 
 DicKixsox, 15, 19 
 Edingtox, 493 
 KiMlORN. 19, 21 
 Eesuer(;. 60, 61, 64 
 
 450, 661 
 Emersox, 337 
 Ei'UKAiM, 443 
 
 487 
 Eymax, 219 
 Fergusox. 669 
 Fi;tterhoff, 475 
 Foster. 219 
 FoiRxiER. 629, 631 
 Frkei.axi>. 582 
 Frexch, 43, 91, 120 
 Frei'Dexthal, 135, 151, 154. 424, 476, 479 
 Frieuberg (Staxtox a.), 264 
 Friedexwai.d. 131 
 Froxixg. 135 
 Galehsky. 478 
 Gati! ( Otto C. ) , 66, 
 Geriieh, 135 
 Gereiia. 478 
 Gettixgs. 475 
 GucK. 642, 662, 669, 
 Goldsteix. 290, 421 
 GorrsTEix. 237, 239, 
 Graeee. 452 
 
 Grant (Duxdas), 91, 219, 650, 655 
 Gray. 219 
 
 Gr a V.SOX (T. Wray), 521 
 Greex (Horace), 465 
 Grier. 219, 222, 293, 295, 360 
 GrisEZ. 12, 15, 44, 
 
 452, 468, 484, 490, 
 
 537, 539 
 GlTHRIE, 493 
 
 Hacker, 501 
 Haiix. 668 
 HA.IEK. 116 
 Hai.steai). 488, 569 
 Hare (Houart A.), 
 Harmer (Dovgeas), 441, 655 
 1! ARi:is (Thomas J.), 424 
 Hays. 131 
 
 llEII.ER, 240 
 
 Henderson (Yanhei.e), 262 
 
 Henke, 135 
 
 Heryxg, 116, 628 
 
 HiCKEY, 219 
 
 Hill, 15, 18, 512, 513, 655 
 
 HixsiiiRG, 135, 276, 303 
 
 Hodge, 576 
 
 HOELSCIIER. 135, 154 
 
 Holding. 219 
 
 Hoi'Maxx. 135 
 
 Horn. 478 
 
 HoRXE (.loiisox), 665 
 
 HORRO<K, 521 
 
 202, 248, 292, 436, 
 492, 507, 524, 525, 
 
 64
 
 XXIV 
 
 INDEX. 
 
 Howard. (C. P.), 299 
 
 HoHSLEY (J. Sheltox), 614 
 
 Ho\v.uiTH (G.), Ill, 135, 198, 303, 440. 
 
 458, 556, 629, 631 
 Hubbard. 3o3 
 Hi. XT. 608 
 luLAUER, 135, 148, 199, 216, 226, 245, 
 
 299, 326, 538 
 IxGALs. 12, 13, 15, 27, 28, 40, 52, 56, 63, 
 
 216, 245, 276, 279, 290, 300, 301, 359, 
 
 467 
 ixgersol. 443 
 Jaxeway. 65, 73, 320, 450, 568, 569, 577- 
 
 578 
 Jekvet. 283 
 
 JoiixsTox (Geo. C), 219, 222, 226 
 JoiiNSTox (Richard H. ), 16, 18, 85, 86 
 JoXES (Clemext R.), 521 
 JoxES (E. L.), 423 
 Kahler. 17, 102, 103, 135, 144, 151, 169, 
 
 197, 201, 245, 246, 264, 341, 443, 460, 
 
 468, 171, 485, 546 
 K.\tzexsteix, 135, 151, 420 
 Keen, 669 
 
 Keith (Arthur), 540 
 Kei.ly (Browx), 52. 463, 493, 510, 
 
 512, 524, 655 
 KiELiAX. 12, 27, 32, 34, 90, 102, 133, 180, 
 
 181, 202, 245, 264, 284, 291, 296, 304, 
 
 324, 356, 424, 465, 466, 541, 569, 635 
 KiR.STEix, 12, 17, 27, 28. 79, 81, 102, 133, 
 
 142, 143, 144, 145, 202, 264 
 Kleestadt. 135, 151 
 Knight (Chas. H.), 613 
 KoB, 433 
 kollicker. 501 
 Kov.vcs. 501 
 Kyi.e (D. Bradfx), 304, 334, 356, 357, 
 
 481 
 Lack (H. Lamdert), 463 
 Lake (Rkhard), 650, 655 
 Laxge, 219 
 Lautexschaeger, 135 
 Leonard, 219 
 Lerche, 521 
 Levinger. 433 
 Levy. 492 
 Lewisohx, 15 
 Liebauet. 52, 182, 511 
 Lester. 40, 272 
 Lockard, 112 
 LoEB. 427 
 
 Low (Stuart), 655 
 Lyxah. 620 
 
 Lyxch (R. C). 230, 245, 422 
 Ma(Fareaxe, 299 
 Macheestox. 433 
 Mackenzie (Morrell), 239, 240 
 M.\cKixxiE. 524 
 I\lAcREyN0LU.s. 494, 523 
 Makuen (Ht-dson), 286 
 Manx. 151, 431, 443 
 
 M.VRIXE. 319, 320 
 
 Masterman. 292 
 
 jMathiev, 32 
 
 Mayer (Emil), 56, 154. 250, 432, 465 
 
 617, 622 
 Mayer (VViei.y), 450, .538 
 Maylarb, 493 
 Mazzociii. 424 
 McAlli.ster. 512 
 McCready (Homer), 38, 39 
 McKee. 68, 39 
 McKenzie, 655 
 AIehnebt. 52, 178 
 Meltzer. 65, 67, 73, 320 
 Melzi, 628 
 Mexges. 219, 222 
 Mermod, 116, 118 
 Meyer (Jes.se), 502, 521 
 Mikulicz. 180, 185, 191, 572 
 Miller (Clifton M.), 614 
 MiLLiGAX (W.), 655 
 Millspaugh. 356 
 
 MiTHOEFER. 326 
 
 Molixte, 670, 672 
 
 MosHER. 13, 14, 16, 19, 24, 26, 32, 42, 
 
 52, 56, 85, 195, 262, 269, 353, 443, 519, 
 
 626 
 Moure. 66, 632, 650, 655 
 MoUEET, 82, 83 
 
 Murphy (J. W.), 233, 538 
 
 
 
 Mrssox (Emma E.) 
 
 , 468, 47 
 
 8 
 
 
 Neukirch, 
 
 551 
 
 
 
 
 
 Nowatxy. 
 
 478 
 
 
 
 
 
 O'Dwyer. 
 
 622, 624 
 
 
 
 
 
 Paxcoast. 
 
 219 
 
 
 
 
 
 Parker. 4' 
 
 •6 
 
 
 
 
 
 Paterson 
 
 (D. R.), 
 
 32, 
 
 251, 
 
 275, 
 
 352 
 
 354, 360, 
 
 463 
 
 
 
 
 
 Patterson 
 
 ( Ellen ) , 
 
 13, 
 
 21, 
 
 28, 51 
 
 , 64 
 
 65, 103, 
 
 216, 256, 
 
 264, 
 
 313 
 
 439, 
 
 455 
 
 483, 588 
 
 599. 608, 
 
 618, 
 
 619 
 
 , 622, 
 
 639 
 
 666, 402 
 
 
 
 
 
 
 Peters. 39 
 
 40, 332 
 
 
 
 
 
 Pfahler. 
 
 219, 222 
 
 
 
 
 
 Phillips (Wexdell C), 16, 17, 21 
 
 Plumjier. 42, 521 
 
 Pollatscheck. 135 
 
 Polyak, 424 
 
 Porter (W. G.), 332 
 
 Pratt. 15, 16, 64 
 
 Preobraschexsky, 239 
 
 Price (H. T.), 234, 340 
 
 QuiXBY. 65 
 
 Reich. 433 
 
 Reichert. 140, 143 
 
 Rexdi- (Robert), 577 
 
 Richards (Geo. L.), 40, 234, 290, 301. 
 
 476, 614 
 Richardson, 290 
 RoBixsox. 65 
 Roe, 319 
 Rogers (.Tonx). 624
 
 INDEX. 
 
 XXV 
 
 Rose, 79, 80, 119, 190, 202, 264 
 
 RoSK.Now. 570 
 
 Ross, 576 
 
 ROVGKT. 511 
 
 RuG(ii. 628 
 
 Sajous. 58, 64 
 
 SAN-nKit (Fhank D.), 56 
 
 SAi!(iNo.v. 262, 292, 500, 628, 635, 639 
 
 Saiki!. 432 
 
 Schmidt (Mohitzi, 91 
 
 Scn.Mii:uKi,o\v, 624 
 
 SCIIOO.NMAKKI!, 13 
 SCIIIIOKTTKI! (\\), 240. 4;!1 
 Sciiwi.NX. 476 
 Skkt.ic. 444, 445 
 
 Sf:iii-i:i!T. 135, 144, 147, 148, 151, 154 
 Skmon. 91, 108, 240, 338, 424, 437, 442, 
 542, 650, 655, 667 
 
 Sl.'MOI.KKI, 135 
 
 Simpson, 91, 234, 622 
 
 SiPPKY. 537 
 
 Sr.iDKu (Grekxfiki.d), 334 
 
 Smith (Hahmo.n), 267, 424 
 
 Smith (Wm. Biuck), 241 
 
 Snow. 241 
 
 SOITHKBLAM) (G. A.), 463 
 
 Spikss, 431 
 
 Staiu K, 550 
 
 STiaiF. 576 
 
 Stkix (Otto), 433 
 
 Stf.inf.r, 135, 154 
 
 STErnx, 544 
 
 Stoerk. 501 
 
 Stokat. 135 
 
 Sti-cky {.Ioskph a.), 64. 238. 425, 427 
 
 Stucky ( Wii.i.iam I. 64 
 Swaix, 91, 617 
 
 SYLVKfSllOR, 585 
 
 Symoxds (Chautkus), 451-452 
 
 Taunz. 485 
 
 THiiisEX. 443 
 
 Thomp.sox (.John A.), 421 
 
 Thomson (St. Ci.ahi), 91, 240, 292, 329- 
 
 330, 420, 422, 463, 648, 650, 655, 659, 
 
 663 
 Thost. 629 
 TiLLEY, 91, 199, 219, 290, 292, 561, 650, 
 
 655 
 Tod (Huxter), 655 
 Todd. 233 
 
 Trexdeeexderg. 66, 78, 287, 668 
 Trotsseav. 599, 604, 609 
 TiRNER (Lor.Ax), 263, .580, 655 
 
 VltiXARD, 628 
 
 Vox Ekkex. 90, 181, 227, 234, 239, 245, 
 
 263, 432, 485 
 Vox S<-hroetter. 261 
 Wadmack. 433 
 
 Waggette, 96, 195, 251, 337, 483 
 VVeixgaertxer, 148 
 Weli..'^. 421 
 
 Williams (Watsox), 655 
 Wixsi.ow, 56, 292 
 WOLIE, 135, 151 
 Wood (Geo. P.), 238, 319 
 Woods (Sir Rorkrt), 433, 442, 673 
 Wright (Joxatiiax), 107 
 Wylie. 420 
 
 Yaxkai-er. 16, 28, 41, 5G, 279 
 Zenker. 180, ..41
 
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