This book is one of the pioneering works in laryngology. The original text is from the library of Indiana University Department of Otolaryngology-Head and Neck Surgery, Bruce Matt, MD. It was scanned, converted to text, and proofed by Alex Tawadros.
BRONCHOSCOPY AND ESOPHAGOSCOPY
A Manual of Peroral Endoscopy and Laryngeal Surgery
CHEVALIER JACKSON, M.D., F.A.C.S. Professor of Laryngology, Jefferson Medical College, Philadelphia; Professor of Bronchoscopy and Esophagoscopy, Graduate School of Medicine, University of Pennsylvania; Member of the American Laryngological Association; Member of the Laryngological, Rhinological, and Otological Society; Member of the American Academy of Ophthalmology and Oto-Laryngology; Member of the American Bronchoscopic Society; Member of the American Philosophical Society; etc., etc.
With 114 Illustrations and Four Color Plates
Philadelphia And London W. B. Saunders Company 1922 Copyrights 1922, by W. B. Saunders Company Made in U.S.A.
TO MY MOTHER TO WHOSE INTEREST IN MEDICAL SCIENCE THE AUTHOR OWES HIS INCENTIVE, AND TO MY FATHER WHOSE CONSTANT ADVICE TO "EDUCATE THE EYE AND THE FINGERS" SPURRED THE AUTHOR TO CONTINUAL EFFORT, THIS BOOK IS AFFECTIONATELY DEDICATED.
This book is based on an abstract of the author's larger work, Peroral Endoscopy and Laryngeal Surgery. The abstract was prepared under the author's direction by a reader, in order to get a reader's point of view on the presentation of the subject in the earlier book. With this abstract as a starting point, the author has endeavored, so far as lay within his limited abilities, to accomplish the difficult task of presenting by written word the various purely manual endoscopic procedures. The large number of corrections and revisions found necessary has confirmed the wisdom of the plan of getting the reader's point of view; and these revisions, together with numerous additions, have brought the treatment of the subject up to date so far as is possible within the limits of a working manual. Acknowledgment is due the personnel of the W. B. Saunders Company for kindly help.
CHEVALIER JACKSON. OCTOBER, 1922. II
CHAPTER I INSTRUMENTARIUM 17 CHAPTER II ANATOMY OF LARYNX, TRACHEA, BRONCHI AND ESOPHAGUS, ENDOSCOPICALLY CONSIDERED 52 CHAPTER III PREPARATION OF THE PATIENT FOR PERORAL ENDOSCOPY 63 CHAPTER IV ANESTHESIA FOR PERORAL ENDOSCOPY 65 CHAPTER V BRONCHOSCOPIC OXYGEN INSUFFLATION 71 CHAPTER VI POSITION OF THE PATIENT FOR PERORAl ENDOSCOPY 73 CHAPTER VII DIRECT LARYNGOSCOPY 82 CHAPTER VIII DIRECT LARYNGOSCOPY (Continued) 91 CHAPTER IX INTRODUCTION OF THE BRONCHOSCOPE 97 CHAPTER X INTRODUCTION OF THE ESOPHAGOSCOPE 106 CHAPTER XI ACQUIRING SKILL 117 CHAPTER XII FOREIGN BODIES IN THE AIR AND FOOD PASSAGES 126 CHAPTER XIII FOREIGN BODIES IN THE LARYNX AND TRACHEOBRONCHIAL TREE 149 CHAPTER XIV REMOVAL OF FOREIGN BODIES FROM THE LARYNX 156 CHAPTER XV MECHANICAL PROBLEMS OF BRONCHOSCOPIC FOREIGN BODY EXTRACTION 158 CHAPTER XVI FOREIGN BODIES IN THE BRONCHI FOR PROLONGED PERIODS 177 CHAPTER XVII UNSUCCESSFUL BRONCHOSCOPY FOR FOREIGN BODIES 181 CHAPTER XVIII FOREIGN BODIES IN THE ESOPHAGUS 183 CHAPTER XIX ESOPHAGOSCOPY FOR FOREIGN BODY 187 CHAPTER XX PLEUROSCOPY 199 CHAPTER XXI BENIGN GROWTHS IN THE LARYNX 201 CHAPTER XXII BENIGN GROWTHS IN THE LARYNX (Continued) 203 CHAPTER XXIII BENIGN GROWTHS PRIMARY IN THE TRACHEOBRONCHIAL TREE 207 CHAPTER XXIV BENIGN NEOPLASMS OF THE ESOPHAGUS 209 CHAPTER XXV ENDOSCOPY IN MALIGNANT DISEASE OF THE LARYNX 210 CHAPTER XXVI BRONCHOSCOPY IN MALIGNANT GROWTHS OF THE TRACHEA 214 CHAPTER XXVII MALIGNANT DISEASE OF THE ESOPHAGUS 216 CHAPTER XXVIII DIRECT LARYNGOSCOPY IN DISEASES OF THE LARYNX 221 CHAPTER XXIX BRONCHOSCOPY IN DISEASES OF THE TRACHEA AND BRONCHI 224 CHAPTER XXX DISEASES OF THE ESOPHAGUS 235 CHAPTER XXXI DISEASES OF THE ESOPHAGUS (Continued) 245 CHAPTER XXXII DISEASES OF THE ESOPHAGUS (Continued) 251 CHAPTER XXXIII DISEASES OF THE ESOPHAGUS (Continued) 260 CHAPTER XXXIV DISEASES OF THE ESOPHAGUS (Continued) 268 CHAPTER XXXV GASTROSCOPY 273 CHAPTER XXXVI ACUTE STENOSIS OF THE LARYNX 277 CHAPTER XXXVII TRACHEOTOMY 279 CHAPTER XXXVIII CHRONIC STENOSIS OF THE LARYNX AND TRACHEA 300 CHAPTER XXXIX DECANNULATION AFTER CURE OF LARYNGEAL STENOSIS 309 BIBLIOGRAPHY 311 INDEX 315
 CHAPTER I—INSTRUMENTARIUM
Direct laryngoscopy, bronchoscopy, esophagoscopy and gastroscopy are procedures in which the lower air and food passages are inspected and treated by the aid of electrically lighted tubes which serve as specula to manipulate obstructing tissues out of the way and to bring others into the line of direct vision. Illumination is supplied by a small tungsten-filamented, electric, "cold" lamp situated at the distal extremity of the instrument in a special groove which protects it from any possible injury during the introduction of instruments through the tube. The bronchi and the esophagus will not allow dilatation beyond their normal caliber; therefore, it is necessary to have tubes of the sizes to fit these passages at various developmental ages. Rupture or even over-distention of a bronchus or of the thoracic esophagus is almost invariably fatal. The armamentarium of the endoscopist must be complete, for it is rarely possible to substitute, or to improvise makeshifts, while the bronchoscope is in situ. Furthermore, the instruments must be of the proper model and well made; otherwise difficulties and dangers will attend attempts to see them.
Laryngoscopes.—The regular type of laryngoscope shown in Fig. I (A, B, C) is made in adult's, child's, and infant's sizes. The instruments have a removable slide on the top of the tubular portion of the speculum to allow the removal of the laryngoscope after the insertion of the bronchoscope through it. The infant size is made in two forms, one with, the other without a removable slide; with either form the larynx of an infant can be exposed in but a few seconds and a definite diagnosis made, without anesthesia, general or local; a thing possible by no other method. For operative work on the larynx of adults, such as the removal of benign growths, particularly when these are situated in the anterior portion of the larynx, a special tubular laryngoscope having a heart-shaped lumen and a beveled tip is used. With this instrument the anterior commissure is readily exposed, and because of this it is named the anterior commissure laryngoscope (Fig. 1, D). The tip of the anterior commissure laryngoscope can be used to expose either ventricle of the larynx by lifting the ventricular band, or it may be passed through the adult glottis for work in the subglottic region. This instrument may also be used as an esophageal speculum and as a pleuroscope. A side-slide laryngoscope, used with or without the slide, is occasionally useful.
Bronchoscopes.—The regular bronchoscope is a hollow brass tube slanted at its distal end, and having a handle at its proximal or ocular extremity. An auxiliary canal on its under surface contains the light carrier, the electric bulb of which is situated in a recess in the beveled distal end of the tube. Numerous perforations in the distal part of the tube allow air to enter from other bronchi when the tube-mouth is inserted into one whose aerating function may be impaired. The accessory tube on the upper surface of the bronchoscope ends within the lumen of the bronchoscope, and is used for the insufflation of oxygen or anesthetics, (Fig. 2, A, B, C, D).
For certain work such as drainage of pulmonary abscesses, the lavage treatment of bronchiectasis and for foreign-body or other cases with abundant secretions, a drainage-bronchoscope is useful The drainage canal may be on top, or on the under surface next to the light-carrier canal. For ordinary work, however, secretion in the bronchus is best removed by sponge-pumping (Q.V.) which at the same time cleans the lamp. The drainage bronchoscope may be used in any case in which the very slightly-greater area of cross section is no disadvantage; but in children the added bulk is usually objectionable, and in cases of recent foreign-body, secretions are not troublesome.
As before mentioned, the lower air passages will not tolerate dilatation; therefore, it is necessary never to use tubes larger than the size of the passages to be examined. Four sizes are sufficient for any possible case, from a newborn infant to the largest adult. For infants under one year, the proper tube is the 4 mm. by 30 cm.; the child's size, 5 mm. by 30 cm., is used for children aged from one to five years. For children six years or over, the 7 mm. by 40 cm. bronchoscope (the adolescent size) can be used unless the smaller bronchi are to be explored. The adult bronchoscope measures 9 mm. by 40 cm.
The author occasionally uses special sizes, 5 mm. x 45 cm., 6 mm. x 35 cm., 8 mm. x 40 cm.
Esophagoscopes.-The esophagoscope, like the bronchoscope, is a hollow brass tube with beveled distal end containing a small electric light. It differs from the bronchoscope in that it has no perforations, and has a drainage canal on its upper surface, or next to the light-carrier canal which opens within the distal end of the tube. The exact size, position, and shape of the drainage outlets is important on bronchoscopes, and to an even greater degree on esophagoscopes. If the proximal edge of the drainage outlet is too near the distal end of the endoscopic tube, the mucosa will be drawn into the outlet, not only obstructing it, but, most important, traumatizing the mucosa. If, for instance, the esophagoscope were to be pushed upon with a fold thus anchored in the distal end, the esophageal wall could easily be torn. To admit the largest sizes of esophagoscopic bougies (Fig. 40), special esophagoscopes (Fig. 5) are made with both light canal and drainage canal outside the lumen of the tube, leaving the full area of luminal cross-section unencroached upon. They can, of course, be used for all purposes, but the slightly greater circumference is at times a disadvantage. The esophageal and stomach secretions are much thinner than bronchial secretions, and, if free from food, are readily aspirated through a comparatively small canal. If the canal becomes obstructed during esophagoscopy, the positive pressure tube of the aspirator is used to blow out the obstruction. Two sizes of esophagoscopes are all that are required—7 mm. X 45 cm. for children, and 10 mm. X 53 cm. for adults (Fig. 3, A and B); but various other sizes and lengths are used by the author for special purposes.* Large esophagoscopes cause dangerous dyspnea in children. If, it is desired to balloon the esophagus with air, the window plug shown in Fig. 6, is inserted into the proximal end of the esophagoscope, and air insufflated by means of the hand aspirator or with a hand bulb. The window can be replaced by a rubber diaphragm with a perforation for forceps if desired. It will be noted that none of the endoscopic tubes are fitted with mandrins. They are to be introduced under the direct guidance of the eye only. Mandrins are obtainable, but their use is objectionable for a number of reasons, chief of which is the danger of overriding a foreign body or a lesion, or of perforating a lesion, or even the normal esophageal wall. The slanted end on the esophagoscope obviates the necessity of a mandrin for introduction. The longer the slant, with consequent acuting of the angle, the more the introduction is facilitated; but too acute an angle increases the risk of perforating the esophageal wall, and necessitates the utmost caution. In some foreign-body cases an acute angle giving a long slant is useful, in others a short slant is better, and in a few cases the squarely cut-off distal end is best. To have all of these different slants on hand would require too many tubes. Therefore the author has settled upon a moderate angle for the end of both esophagoscopes and bronchoscopes that is easy to insert, and serves all purposes in the version and other manipulations required by the various mechanical problems of foreign-body extraction. He has, however, retained all the experimental models, for occasional use in such cases as he falls heir to because of a problem of extraordinary difficulty.
* A 9 mm. X 45 cm. esophagoscope will reach the stomach of almost all adults and is somewhat easier to introduce than the 10 mm. X 53 cm., which may be omitted from the set if economy must be practiced.
[FIG. I.—Author's laryngoscopes. These are the standard sizes and fulfill all requirements. Many other forms have been devised by the author, but have been omitted from the list as unnecessary. The infant diagnostic laryngoscope (C) is not for introducing bronchoscopes, and is not absolutely necessary, as the larynx of any infant can be inspected with the child's size laryngoscope (B).
A Adult's size; B, child's size; C, infant's diagnostic size; D, anterior commissure laryngoscope; E, with drainage canal; 17, intubating laryngoscope, large lumen. All the laryngoscopes are preferred without drainage canals.]
[FIG. 2.—The author's bronchoscopes of the sizes regularly used. Various other lengths and diameters are on hand for occasional use for special purposes. With the exception of a 6 mm. X 35 cm. size for older children, these special bronchoscopes are very rarely used and none of them can be regarded as necessary. For special purposes, however, special shapes of tube-mouth are useful, as, for instance, the oval end to facilitate the getting of both points of a staple into the tube-mouth The illustrated instruments are as follows:
A, Infant's size, 4 mm. X 30 cm.; B, child's size, 5 mm. X 30 cm.; C, adolescent's size, 7 mm. X 40 cm.; D, adult's size, 9 mm. X 40 cm.; E, aspirating bronchoscope made in all the foregoing sizes, and in a special size, 5 mm. X 45 cm.]
[FIG. 3.—The author's esophagoscopes of the sizes he has standardized for all ordinary requirements. He uses various other lengths and sizes for special purposes, but none of them are really necessary. A gastroscope, 10 mm. X 70 cm., is useful for adults, especially in cases of gastroptosis. Drainage canals are placed at the top or at the side of the tube, next to the light-carrier canal.
A, Adult's size, 10 mm. X 53 cm.; B, child's size, 7 mm. X 45 cm.; C and D, full lumen, with both light canal and drainage canal outside the wall of the tube, to be used for passing very large bougies. This instrument is made in adult, child, and adolescent (8 mm. by 45 cm.) sizes. Gastroscopes and esophagoscopes of the sizes given above (A) and (B), can be used also as gastroscopes. A small form of C, 5 mm. X 30 cm. is used in infants, and also as a retrograde esophagoscope in patients of any age. E, window plug for ballooning gastroscope, F.]
[FIG. 4.—Author's short esophagoscopes and esophageal specula A, Esophageal speculum and hypopharyngoscope, adult's size; B, esophageal speculum and hypopharyngoscope, child's size; C, heavy handled short esophagoscope; D, heavy handled short esophagoscope with drainage.]
[FIG. 5.—Cross section of full-lumen esophagoscope for the use of largest bourgies. The canals for the light carrier and for drainage are so constructed that they do not encroach upon the lumen of the tube.]
 The special sized esophagoscopes most often useful are the 8 mm. X 30 cm., the 8 mm. X 45 cm., and the 5 mm. X 45 cm. These are made with the drainage canal in various positions.
For operations on the upper end of the esophagus, and particularly for foreign body work, the esophageal speculum shown at A and B, in Fig. 4, is of the greatest service. With it, the anterior wall of the post-cricoidal pharynx is lifted forward, and the upper esophageal orifice exposed. It can then be inserted deeper, and the upper third of the esophagus can be explored. Two sizes are made, the adult's and the child's size. These instruments serve, very efficiently as pleuroscopes. They are made with and without drainage canals, the latter being the more useful form.
[FIG. 6.—Window-plug with glass cap interchangeable with a cap having a rubber diaphragm with a perforation so that forceps may be used without allowing air to escape. Valves on the canals (E, F, Fig. 3) are preferable.]
Gastroscopes.—The gastroscope is of the same construction as the esophagoscope, with the exception that it is made longer, in order to reach all parts of the stomach. In ordinary cases, the regular esophagoscopes for adults and children respectively will afford a good view of the stomach, but there are cases which require longer tubes, and for these a gastroscope 10 mm. X 70 cm. is made, and also one 10 mm. X 80 cm., though the latter has never been needed but once.
 Pleuroscopes.—As mentioned above the anterior commissure laryngoscope and the esophageal specula make very efficient pleuroscopes; but three different forms of pleuroscopes have been devised by the author for pleuroscopy. The retrograde esophagoscope serves very well for work through small fistulae.
Measuring Rule (Fig. 7).—It is customary to locate esophageal lesions by denoting their distance from the incisor teeth. This is readily done by measuring the distance from the proximal end of the esophagoscope to the upper incisor teeth, or in their absence, to the upper alveolar process, and subtracting this measurement from the known length of the tube. Thus, if an esophagoscope 45 cm. long be introduced and we find that the distance from the incisor teeth to the ocular end of the esophagoscope as measured by the rule is 20 cm., we subtract this 20 cm. from the total length of the esophagoscope (45 cm.) and then know that the distal end of the tube is 25 cm. from the incisor teeth. Graduation marks on the tube have been used, but are objectionable.
[FIG. 7.—Measuring rule for gauging in centimeters the depth of any location by subtraction of the length of the uninserted portion of the esophagoscope or bronchoscope. This is preferable to graduations marked on the tubes, though the tubes can be marked with a scale if desired.]
Batteries.—The simplest, best, and safest source of current is a double dry battery arranged in three groups of two cells each, connected in series (Fig. 8). Each set should have two binding posts and a rheostat. The binding posts should have double holes for two additional cords, to be kept in reserve for use in case a cord becomes defective.* The commercial current reduced through a rheostat should never be used, because there is always the possibility of "grounding" the circuit through the patient; a highly dangerous accident when we consider that the tube makes a long moist contact in tissues close to the course of both the vagi and the heart. The endoscopist should never depend upon a pocket battery as a source of illumination, for it is almost certain to fail during the endoscopy. The wires connecting the battery and endoscopic instrument are covered with rubber, so that they may be cleansed and superficially sterilized with alcohol. They may be totally immersed in alcohol for any length of time without injury.
* When this is done care is necessary to avoid attempting to use simultaneously the two cords from one pair of posts.
[FIG 8.—The author's endoscopic battery, heavily built for reliability.
It contains 6 dry cells, series-connected in 3 groups of 2 cells each. Each group has its own rheostat and pair of binding posts.]
Aspirating Tubes.—Independent aspirating tubes involve delay in their use as compared to aspirating canals in the wall of the endoscopic tube; but there are special cases in which an independent tube is invaluable. Three forms are used by the author. The "velvet eye" cannot traumatize the mucosa (Fig. 9). To hold a foreign body by suction, a squarely cut off end is necessary. For use through the tracheotomic wound without a bronchoscope a malleable tube (Fig. 10) is better.
[FIG. 9.—The author's protected-aperture endoscopic aspirating tube for aspiration of pharyngeal secretions during direct laryngoscopy and endotracheobronchial secretions at bronchoscopy, also for draining retropharyngeal abscesses. The laryngoscopes are obtainable with drainage canals, but for most purposes the independent aspirating tube shown above is more satisfactory. The tubes are made in 20 30, 40, and 60 cm. lengths. An aperture on both sides prevents drawing in the mucosa. It can be used for insufflation of ether if desired. An aspirating tube of the same design, but having a squarely cut off end, is sometimes useful for removing secretions lying close to a foreign body; for removing papillomata; and even for withdrawing foreign bodies of a soft surface consistency. It is not often that the foreign bodies can be thus withdrawn through the glottis, but closely fitting foreign bodies can at least be withdrawn to a higher level at which ample forceps spaces will permit application of forceps. Such aspirating tubes, however, are not so safe to use as the protected, double aperture tubes.]
[FIG. 10.—The author's malleable tracheotomic aspirating tube for removal of secretions, exudates, crusts, etc., from the tracheobronchial tree through the tracheotomic wound without a bronchoscope. The tube is made of copper so that it can be bent to any curve, and the copper wire stylet prevents kinking. The stylet is removed before using the tube for aspiration.]
 Aspirators.—The various electric aspirators so universally used in throat operations should be utilized to withdraw secretions in the tubes fitted with drainage canals. They, however, have the disadvantages of not being easily transported, and of occasionally being out of order. The hand aspirator shown in Fig. 11 is, therefore, a necessary part of the instrumental equipment. It never fails to work, is portable, and affords both positive and negative pressures. The positive pressure is sometimes useful in clearing the drainage canal of any particles of food, tissue, clots, or secretion which may obstruct it; and it also serves to fill the stomach or esophagus with air when the ballooning procedure is used. The mechanical aspirator (Fig. 12) is highly efficient and is the one used in the Bronchoscopic Clinic. The positive pressure will quickly clear obstructed drainage canals, and may be used while the esophagoscope is in situ, by simply detaching the minus pressure tube and attaching the plus pressure. In the lungs, however, high plus pressures are so dangerous that the pressure valve must be lowered.
[Fig. 11—Portable aspirator for endoscopy with additional tube connected with the plus pressure side for use in case of occlusion of the drainage canal. This aspirator has the advantage of great power with portability. Where portability is not required the electrically operated aspirator is better.]
[FIG. 12.—Robinson mechanical aspirator adapted for bronchoscopic and esophagoscopic aspiration by the author. The positive pressure is used for clearing obstructed drainage canals and tubes.]
[FIG. 13.—Apparatus for insufflation of ether or chloroform during bronchoscopy, for those who may desire to use general anesthesia. The mechanical methods of intratracheal insufflation anesthesia subsequently developed by Meltzer and Auer, Elsberg, Geo. P. Muller and others have rightly superseded this apparatus for all general surgical purposes.]
Sponge-pumping.—While the usually thin, watery esophageal and gastric secretions, if free from food, are readily aspirated through a drainage canal, the secretions of the bronchi are often thick and mucilaginous and aspirated with difficulty. Further-more, bronchial secretions as a rule are not collected in pools, but are distributed over the walls of the larger bronchi and continuously well up from smaller bronchi during cough. The aspirating bronchoscopes should be used whenever their very slight additional area of cross-section is unobjectionable. In most cases, however, the most advantageous way to remove bronchial secretion has been found to be by introducing a gauze swab on a long sponge carrier (Fig. 14), so that the sponge extends beyond the distal end of the bronchoscope, causing cough. Then withdrawal of the sponge carrier will remove all of the secretion in the tube just as the plunger in a pump will lift all of the water above it. By this maneuver the walls of the bronchus are wiped free from secretions, and the lamp itself is cleansed.
[FIG. 14.—Sponge carrier with long collar for carrying the small sponges shown in Fig. 15. The collar screws down as in the Coolidge cotton carrier. About a dozen of these are needed and they should all be small enough to go through the 4 mm. (diameter) bronchoscope and long enough to reach through the 53 cm. (length) esophagoscope, so that one set will do for all tubes. The schema shows method of sponging. The carrier C, armed with the sponge, S, when rotated as shown by the dart, D, wipes the field, P, at the same time wiping the lamp, L. The lamp does not need ever to be withdrawn for cleaning during bronchoscopy. It is protected in a recess so that it does not catch in the sponges.]
[FIG 15.—Exact size to which the bandage-gauze is cut to make endoscopic sponges. Each rectangle is the size for the tubal diameter given. The dimensions of the respective rectangles are not given because it is easier for the nurse or any one to cut a cardboard pattern of each size directly from this drawing. The gauze rectangles are folded up endwise as shown at A, then once in the middle as at B, then strung one dozen on a safety pin. In America gauze bandages run about 16 threads to the centimeter. Different material might require a slightly different size and the pattern could be made to suit.]
 The gauze sponges are made by the instrument nurse as directed in Fig. 15, and are strung on safety pins, wrapped in paper, the size indicated by a figure on the wrapper, and then sterilized in an autoclave. The sterile packages are opened only as needed. These "bronchoscopic sponges" are also made by Johnston and Johnston, of New Brunswick, N. J. and are sold in the shops.
Mouth-gag.—Wide gagging prevents proper exposure of the larynx by forcing the mandible down on the hyoid bone. The mouth should be gently opened and a bite block (Fig. 16) inserted between the teeth on the left side of the patient's mouth, to prevent closing of the jaws on the delicate bronchoscope or esophagoscope.
[FIG. 16.—Bite block to be inserted between the teeth to prevent closure of the jaws on the endoscopic tube. This is the McKee-McCready modification of the Boyce thimble with the omission of the etherizing tube, which is no longer needed. The block has been improved by Dr. W. F. Moore of the Bronchoscopic Clinic.]
Forceps.—Delicacy of touch and manipulation are an absolute necessity if the endoscopist is to avoid mortality; therefore, heavily built and spring-opposed forceps are dangerous as well as useless. For foreign-body work in the larynx, and for the removal of benign laryngeal growths, the alligator forceps with roughened jaws shown in Fig. 17 serve every purpose.
[FIG. 17.—Laryngeal grasping forceps designed by Mosher. For my own use I have taken off the ratchet-locking device for all general work, to be reapplied on the rare occasions when it is required.]
Bronchoscopic and esophagoscopic grasping forceps are of the tubular type, that is, a stylet carrying the jaws works in a slender tube so that traction on the stylet draws the V of the open jaws into the lumen of the tube, thus causing the blades to approximate. They are very delicate and light, yet have great grasping power and will sustain any degree of traction that it is safe to exert. They permit of the delicacy of touch of a violin bow. The two types of jaws most frequently used, are those with the forward-grasping blades shown in Fig. 18, and those having side-grasping blades shown in Fig. 19. The side-curved forceps are perhaps the most generally useful of all the endoscopic forceps; the side projection of the jaws makes them readily visible during their closure on an object; their broader grasp is also an advantage., The projection of the blades in the side-curved grasping forceps should always be directed toward the left. If it is desired that they open in another direction this should be accomplished by turning the handle and not by adjusting the blade itself. If this rule be followed it will always be possible to tell by the position of the handle exactly where the blades are situated; whereas, if the jaws themselves are turned, confusion is sure to result. The forward-grasping forceps are always so adjusted that the jaws open in an up-and-down direction. On rare occasions it may be deemed desirable to turn the stylet of either forceps in some other direction relative to the handle.
[FIG. 18.—The author's forward grasping tube forceps. The handle mechanism is so simple and delicate that the most exquisite delicacy of touch is possible. Two locknuts and a thumbscrew take up all lost motion yet afford perfect adjustability and easy separation for cleansing. At A is shown a small clip for keeping the jaws together to prevent injurious bending in the sterilizer, or carrying case. At the left is shown a handle-clamp for locking the forceps on a foreign body in the solution of certain rarely encountered mechanical problems. The jaws are serrated and cupped.]
[FIG. 19.—Jaws of the author's side-curved endoscopic forceps. These work as shown in the preceding illustration, each forceps having its own handle and tube. Originally the end of the cannula and stylet were squared to prevent rotation of the jaws in the cannula. This was found to be unnecessary with properly shaped jaws, which wedge tightly.]
Rotation Forceps.—It is sometimes desired to make traction on an irregularly shaped foreign body, and yet to allow the object to turn into the line of least resistance while traction is being made. This can be accomplished by the use of the rotation forceps (Fig. 20), which have for blades two pointed hooks that meet at their points and do not overlap. Rotation forceps made on the model of the laryngeal grasping forceps, but having opposing points at the end of the blades, are sometimes very useful for the removal of irregular foreign bodies in the larynx, or when used through the esophageal speculum they are of great service in the extraction of such objects as bones, pin-buttons, and tooth-plates, from the upper esophagus. These forceps are termed laryngeal rotation forceps (Fig. 31). All the various forms of forceps are made in a very delicate size often called the "mosquito" or "extra light" forceps, 40 cm. in length, for use in the 4 mm. and the 5 mm. bronchoscopes. For the 5 mm. bronchoscopes heavier forceps of the 40 cm. length are made. For the larger tubes the forceps are made in 45 cm., 50 cm., and 60 cm. lengths. A square-cannula forceps to prevent turning of the jaws was at one time used by the author but it has since been found that round cannula pattern serves all purposes.
[FIG. 20.—The author's rotation forceps. Useful to allow turning of an irregular foreign body to a safer relation for withdrawal and for the esophagoscopic removal of safety pins by the method of pushing them into the stomach, turning and withdrawal, spring up.]
Upper-lobe-bronchus Forceps.—Foreign bodies rarely lodge in an upper-lobe bronchus, yet with such a problem it is necessary to have forceps that will reach around a corner. The upper-lobe-bronchus forceps shown in Fig. 27 have curved jaws so made as to straighten out while passing through the bronchoscope and to spring back into their original shape on up from the lower jaw emerging from the distal end of the bronchoscopic tube, the radius of curvature being regulated by the extent of emergence permitted. They are made in extra-light pattern, 40 cm. long, and the regular model 45 cm. long. The full-curved model, giving 180 degrees and reaching up into the ascending branches, is made in both light and heavy patterns. Forceps with less curve, and without the spiral, are used when it is desired to reach only a short distance "around the corner" anywhere in the bronchi. These are also useful, as suggested by Willis F. Manges, in dealing with safety pins in the esophagus or tracheobronchial tree.
[FIG. 21.—Tucker jaws for the author's forceps. The tiny lip projecting down from the upper, and up from the lower jaw prevents sidewise escape of the shaft of a pin, tack, nail or needle. The shaft is automatically thrown parallel to the bronchoscopic axis. Drawing about four times actual size.]
 Tucker Forceps—Gabriel Tucker modified the regular side-curved forceps by adding a lip (Fig. 21) to the left hand side of both upper and lower jaws. This prevents the shaft of a tack, nail, or pin, from springing out of the grasp of the jaws, and is so efficient that it has brought certainty of grasp never before obtainable. With it the solution of the safety-pin problem devised by the author many years ago has a facility and certainty of execution that makes it the method of choice in safety-pin extraction.
[FIG. 22.—The author's down-jaw esophageal forceps. The dropping jaw is useful for reaching backward below the cricopharyngeal fold when using the esophageal speculum in the removal of foreign bodies. Posterior forceps-spaces are often scanty in cases of foreign bodies lodged just below the cricopharyngeus.]
[FIG. 23.—Expansile forceps for the endoscopic removal of hollow foreign bodies such as intubation tubes, tracheal cannulae, caps, and cartridge shells.]
Screw forceps.—For the secure grasp of screws the jaws devised by Dr. Tucker for tacks and pins are excellent (Fig. 21).
Expanding Forceps.—Hollow objects may require expanding forceps as shown in Fig. 23. In using them it is necessary to be certain that the jaws are inside the hollow body before expanding them and making traction. Otherwise severe, even fatal, trauma may be inflicted.
[FIG. 24.—The author's fenestrated peanut forceps. The delicate construction with long, springy and fenestrated jaws give in gentle hands a maximum security with a minimum of crushing tendency.]
[FIG. 25—The author's bronchial dilators, useful for dilating strictures above foreign bodies. The smaller size, shown at the right is also useful as an expanding forceps for removing intubation tubes, and other hollow objects. The larger size will go over the shaft of a tack.]
[FIG. 26.—The author's self-expanding bronchial dilator. The extent of expansion can be limited by the sense of touch or by an adjustable checking mechanism on the handle. The author frequently used smooth forceps for this purpose, and found them so efficient that this dilator was devised. The edges of forceps jaws are likely to scratch the epithelium. Occasionally the instrument is useful in the esophagus; but it is not very safe, unless used with the utmost caution.]
Tissue Forceps.—With the forceps illustrated in Fig. 28 specimens of tissue may be removed for biopsy from the lower air and food passages with ease and certainty. They have a cross in the outer blade which holds the specimen removed. The action is very delicate, there being no springs, and the sense of touch imparted is often of great aid in the diagnosis.
[FIG. 27.—The author's upper-lobe bronchus forceps. At A is shown the full-curved form, for reaching into the ascending branches of the upper-lobe bronchus A number of different forms of jaws are made in this kind of forceps. Only 2 are shown.]
[FIG 28—The author's endoscopic tissue forceps. The laryngeal length is 30 cm. For esophageal use they are made 50 and 60 cm. long. These are the best forceps for cutting out small specimens of tissue for biopsy.]
The large basket punch forceps shown in Fig. 33 are useful in removing larger growths or specimens of tissue from the pharynx or larynx. A portion or the whole of the epiglottis may be easily and quickly removed with these forceps, the laryngoscope introduced along the dorsum of the tongue into the glossoepiglottic recess, bringing the whole epiglottis into view. The forceps may be introduced through the laryngoscope or alongside the tube. In the latter method a greater lateral action of the forceps is obtainable, the tube being used for vision only. These forceps are 30 cm. long and are made in two sizes; one with the punch of the largest size that can be passed through the adult laryngoscope, and a smaller one for use through the anterior-commissure laryngoscope and the child's size laryngoscope.
[FIG. 29.—The author's papilloma forceps. The broad blunt nose will scalp off the growths without any injury to the normal basal tissues. Voice-destroying and stenosing trauma are thus easily avoided.]
[FIG. 30.—The author's short mechanical spoon (30 cm. long).]
Papilloma Forceps.—Papillomata do not infiltrate; but superficial repullulations in many cases require repeated removals. If the basal tissues are traumatized, an impaired or ruined voice will result. The author designed these forceps (Fig. 29) to scalp off the growths without injury to the normal tissues.
[FIG. 31.—The author's laryngeal rotation forceps.]
[FIG. 32.—Enlarged view of the jaws of the author's vocal-nodule forceps. Larger cups are made for other purposes but these tiny cups permit of that extreme delicacy required in the excision of the nodules from the vocal cords of singers and other voice users.]
[FIG 33.-Extra large laryngeal tissue forceps. 30 cm. long, for removing entire growths or large specimens of tissue. A smaller size is made.]
Bronchial Dilators.—It is not uncommon to find a stricture of the bronchus superjacent to a foreign body that has been in situ for a period of months. In order to remove the foreign body, this stricture must be dilated, and for this the bronchial dilator shown in Fig. 25 was devised. The channel in each blade allows the closed dilator to be pushed down over the presenting point of such bodies as tacks, after which the blades are opened and the stricture stretched. A small and a large size are made. For enlarging the bronchial narrowing associated with pulmonary abscess and sometimes found above a bronchiectatic or foreign body cavity, the expanding dilator shown in Fig. 26 is perhaps less apt to cause injury than ordinary forceps used in the same way. The stretching is here produced by the spring of the blades of the forceps and not by manual force. The closed blades are to be inserted through the strictured area, opened, and then slowly withdrawn. For cicatricial stenoses of the trachea the metallic bougies, Fig. 40, are useful. For the larynx, those shown in Fig. 41 are needed.
[FIG. 34.—A, Mosher's laryngeal curette; B, author's flat blade cautery electrode; C, pointed cautery electrode; D, laryngeal knife. The electrodes are insulated with hard-rubber vulcanized onto the conducting wires.]
[FIG. 35.—Retrograde esophageal bougies in graduated sizes devised by Dr. Gabriel Tucker and the author for dilatation of cicatricial esophageal stenosis. They are drawn upward by an endless swallowed string, and are therefore only to be used in gastrostomized cases.]
[FIG. 36.—Author's bronchoscopic and esophagoscopic mechanical spoon, made in 40, 50 and 60 cm. lengths.]
[FIG. 37.—Schema illustrating the author's method of endoscopic closure of open safety pins lodged point upward The closer is passed down under ocular control until the ring, R, is below the pin. The ring is then erected to the position shown dotted at M, by moving the handle, H, downward to L and locking it there with the latch, Z. The fork, A, is then inserted and, engaging the pin at the spring loop, K, the pin is pushed into the ring, thus closing the pin. Slight rotation of the pin with the forceps may be necessary to get the point into the keeper. The upper instrument is sometimes useful as a mechanical spoon for removing large, smooth foreign bodies from the esophagus.]
Esophageal Dilators.—The dilatation of cicatricial stenosis of the esophagus can be done safely only by endoscopic methods. Blind esophageal bouginage is highly dangerous, for the lumen of the stricture is usually eccentric and the bougie is therefore apt to perforate the wall rather than find the small opening. Often there is present a pouching of the esophagus above a stricture, in which the bougie may lodge and perforate. Bougies should be introduced under visual guidance through the esophagoscope, which is so placed that the lumen of the stricture is in the center of the endoscopic field. The author's endoscopic bougies (Fig. 40) are made with a flexible silk-woven tip securely fastened to a steel shaft. This shaft lends rigidity to the instrument sufficient to permit its accurate placement, and its small size permits the eye to keep the silk-woven tip in view. These endoscopic bougies are made in sizes from 8 to 40, French scale. The larger sizes are used especially for the dilatation of laryngeal and tracheal stenoses. For the latter work it is essential that the bougies be inspected carefully before they are used, for should a defective tip come off while in the lower air passages a difficult foreign body problem would be created. Soft-rubber retrograde dilators to be drawn upward from the stomach by a swallowed string are useful in gastrostomized cases (Fig. 35).
[FIG 38.—Half curved hook, 45 cm. and 60 cm. Full curved patterns are made but caution is necessary to avoid them becoming anchored in the bronchi. Spiral forms avoid this. The author makes for himself steel probe-pointed rods out of which he bends hooks of any desired shape. The rod is held in a pin-vise to facilitate bending of the point, after heating in an alcohol or bunsen flame.]
Hooks.—No hook greater than a right angle should be used through endoscopic tubes; for should it become caught in some of the smaller bronchi its extraction might result in serious trauma. The half curved hook shown in Fig. 38 is the safest type; better still, a spiral twist to the hook will add to its uses, and by reversing the turning motion it may be "unscrewed" out if it becomes caught. Hooks may easily be made from rods of malleable steel by heating the end in a spirit lamp and shaping the curve as desired by means of a pin-vise and pliers. About 2 cm. of the proximal end of the rod should be bent in exactly the opposite direction from that of the hook so as to form a handle which will tell the position of the hook by touch as well as by sight. Coil-spring hooks for the upper-lobe-bronchus (Fig. 39) will reach around the corner into the ascending bronchus of the upper-lobe-bronchus, but the utmost skill and care are required to make their use justifiable.
[FIG. 39.—Author's coil-spring hook for the upper-lobe, bronchus]
Safety-pin Closer.—There are a number of methods for the endoscopic removal of open safety-pins when the point is up, one of which is by closing the pin with the instrument shown in Fig. 37 in the following manner. The oval ring is passed through the endoscope until it is beyond the spring of the safety-pin, the ring is then turned upward by depressing the handle, and by the aid of the prong the pin is pushed into the ring, which action approximates the point of the pin and the keeper and closes the pin. Removal is then less difficult and without danger. This instrument may also be used as a mechanical spoon, in which case it may be passed to the side of a difficultly grasped foreign body, such as a pebble, the ring elevated and the object withdrawn. Elsewhere will be found a description of the various safety-pin closers devised by various endoscopists. The author has used Arrowsmith's closer with much satisfaction.
Mechanical Spoon.—When soft, friable substances, such as a bolus of meat, become impacted in the upper esophagus, the short mechanical spoon (Fig. 30) used through the esophageal speculum is of great aid in their removal. The blade in this instrument, as the name suggests, is a spoon and is not fenestrated as is the safety-pin closer, which if used for friable substances would allow them to slip through the fenestration. A longer form for use through bronchoscopes and esophagoscopes is shown in Fig. 36.
A laryngeal curette, cautery electrodes, cautery handle, and laryngeal knife are illustrated in Fig. 34. The cautery is to be used with a transformer, or a storage battery.
Spectacles.—If the operator has no refractive error he will need two pairs of plane protective spectacles with very large "eyes." If ametropic, corrective lenses are necessary, and duplicate spectacles must be in charge of a nurse. For presbyopia two pairs of spectacles for 40 cm. distance and 65 cm. distance must be at hand. Hook temple frames should be used so that they can be easily changed and adjusted by the nurse when the lenses become spattered. The spectacle nurse has ready at all times the extra spectacles, cleaned and warmed in a pan of heated water so that they will not be fogged by the patient's breath, and she changes them without delay as often as they become soiled. The operator should work with both eyes open and with his right eye at the tube mouth. The operating room should be somewhat darkened so as to facilitate the ignoring of the image in the left eye; any lighting should be at the operator's back, and should be insufficient to cause reflections from the inner surface of his glasses.
[FIG. 40.—The author's endoscopic bougies. The end consists of a flexible silk woven tip attached securely to a steel shank. Sizes 8 to 30 French catheter scale. A metallic form of this bougie is useful in the trachea; but is not so safe for esophageal use.]
[FIG. 41.—The author's laryngeal bougie for the dilatation of cicatricial laryngeal stenosis. Made in 10 sizes. The shaded triangle shows the cross-section at the widest part.]
[FIG. 42.—The author's bronchoscopic and esophagoscopic table.]
 Endoscopic Table.—Any operating table may be used, but the work is facilitated if a special table can be had which allows the placing of the patient in all required positions. The table illustrated in fig. 42 is so arranged that when the false top is drawn forward on the railroad, the head piece drops and the patient is placed in the correct (Boyce) position for esophagoscopy or bronchoscopy, i.e., with the head and shoulders extending over the end of the table. By means of the wheel the plane of the table may be altered to any desired angle of inclination or height of head.
Operating Room.—All endoscopic procedures should be performed in a somewhat darkened operating room where all the desired materials are at hand. An endoscopic team consists of three persons: the operator, the assistant who holds the head, and the instrument assistant. Another person is required to hold the patient's arms and still another for the changing of the operator's glasses when they become spattered. The endoscopic team of three maintain surgical asepsis in the matter of hands and gowns, etc. The battery, on a small table of its own, is placed at the left hand of the operator. Beyond it is the table for the mechanical aspirator, if one is used. All extra instruments are placed on a sterile table, within reach, but not in the way, while those instruments for use in the particular operation are placed on a small instrument table back of the endoscopist. Only those instruments likely to be wanted should be placed on the working table, so that there shall be no confusion in their selection by the instrument nurse when called for. Each moment of time should be utilized when the endoscopic procedure has been started, no time should be lost in the hunting or separating of instruments. To have the respective tables always in the same position relative to the operator prevents confusion and avoids delay.
[FIG 43.—The author's retrograde esophagoscope.]
Oxygen Tank and Tracheotomy Instruments.—Respiratory arrest may occur from shifting of a foreign body, pressure of the esophagoscope, tumor, or diverticulum full of food. Rare as these contingencies are, it is essential that means for resuscitation be at hand. No endoscopic procedure should be undertaken without a set of tracheotomy instruments on the sterile table within instant reach. In respiratory arrest from the above mentioned causes, respiratory efforts are not apt to return unless oxygen and amyl nitrite are blown into the trachea either through a tracheotomy opening or better still by means of a bronchoscope introduced through the larynx. The limpness of the patient renders bronchoscopy so easy that the well-drilled bronchoscopist should have no difficulty in inserting a bronchoscope in 10 or 15 seconds, if proper preparedness has been observed. It is perhaps relatively rarely that such accidents occur, yet if preparations are made for such a contingency, a life may be saved which would otherwise be inevitably lost. The oxygen tank covered with a sterile muslin cover should stand to the left of the operating table.
Asepsis.—Strict aseptic technic must be observed in all endoscopic procedures. The operator, first assistant, and instrument nurse must use the same precautions as to hand sterilization and sterile gowns as would be exercised in any surgical operation. The operator and first assistant should wear masks and sterile gloves. The patient is instructed to cleanse the mouth thoroughly with the tooth brush and a 20 per cent alcohol mouth wash. Any dental defects should, if time permit, as in a course of repeated treatments, be remedied by the dental surgeon. When placed on the table with neck bare and the shoulders unhampered by clothing, the patient is covered with a sterile sheet and the head is enfolded in a sterile towel. The face is wiped with 70 per cent alcohol.
It is to be remembered that while the patient is relatively immune to the bacteria he himself harbors, the implantation of different strains of perhaps the same type of organisms may prove virulent to him. Furthermore the transference of lues, tuberculosis, diphtheria, pneumonia, erysipelas and other infective diseases would be inevitable if sterile precautions were not taken.
All of the tubes and forceps are sterilized by boiling. The light-carriers and lamps may be sterilized by immersion in 95 per cent alcohol or by prolonged exposure to formaldehyde gas. Continuous sterilization by keeping them put away in a metal box with formalin pastilles or other source of formaldehyde gas is an ideal method. Knives and scissors are immersed in 95 per cent alcohol, and the rubber covered conducting cords are wiped with the same solution.
List of Instruments.—The following list has been compiled as a convenient basis for equipment, to which such special instruments as may be needed for special cases can be added from time to time. The instruments listed are of the author's design. 1 adult's laryngoscope. 1 child's laryngoscope. 1 infant's diagnostic laryngoscope. 1 anterior commissure laryngoscope. 1 bronchoscope, 4 mm. X 30 cm. 1 bronchoscope, 5 mm. X 30 cm. 1 bronchoscope, 7 mm. X 40 cm. 1 bronchoscope, 9 mm. X 40 cm. 1 esophagoscope, 7 mm. X 45 cm. 1 esophagoscope, 10 mm. X 53 cm. 1 esophagoscope, full lumen, 7 mm. X 45 cm. 1 esophagoscope, full lumen, 9 mm. X 45 cm. 1 esophageal speculum, adult. 1 esophageal speculum, child. 1 forward-grasping forceps, delicate, 40 cm. 1 forward-grasping forceps, regular, 50 cm. 1 forward-grasping forceps, regular, 60 cm. 1 side-grasping forceps, delicate, 40 cm. 1 side-grasping forceps, regular, 50 cm. 1 side-grasping forceps, regular, 60 cm. 1 rotation forceps, delicate, 40 cm. 1 rotation forceps, regular, 50 cm. 1 rotation forceps, regular, 60 cm. 1 laryngeal alligator forceps. 1 laryngeal papilloma forceps. 10 esophageal bougies, Nos. 8 to 17 French (larger sizes to No. 36 may be added). 1 special measuring rule. 6 light sponge carriers. 1 aspirator with double tube for minus and plus pressure. 2 endoscopic aspirating tubes 30 and 50 cm. 1 half curved hook, 60 cm. 1 triple circuit bronchoscopy battery. 6 rubber covered conducting cords for battery. 1 box bronchoscopic sponges, size 4. 1 box bronchoscopic sponges, size 5. 1 box bronchoscopic sponges, size 7. 1 box bronchoscopic sponges, size 10. 1 bite block, 1 adult. 1 bite block, child. 2 dozen extra lamps for lighted instruments. 1 extra light carrier for each instrument.* 4 yards of pipe-cleaning, worsted-covered wire.
[* Messrs. George P. Pilling and Sons who are now making these instruments supply an extra light carrier and 2 extra lamps with each instrument.]
Care of Instruments.—The endoscopist must either personally care for his instruments, or have an instrument nurse in his own employ, for if they are intrusted to the general operating room routine he will find that small parts will be lost; blades of forceps bent, broken, or rusted; tubes dinged; drainage canals choked with blood or secretions which have been coagulated by boiling, and electric attachments rendered unstable or unservicable, by boiling, etc. The tubes should be cleansed by forcing cold water through the drainage canals with the aspirating syringe, then dried by forcing pipe-cleaning worsted-covered wire through the light and drainage canals. Gauze on a sponge carrier is used to clean the main canal. Forceps stylets should be removed from their cannulae, and the cannulae cleansed with cold water, then dried and oiled with the pipe-cleaning material. The stylet should have any rough places smoothed with fine emery cloth and its blades carefully inspected; the parts are then oiled and reassembled. Nickle plating on the tubes is apt to peel and these scales have sharp, cutting edges which may injure the mucosa. All tubes, therefore, should be unplated. Rough places on the tubes should be smoothed with the finest emery cloth, or, better, on a buffing wheel. The dry cells in the battery should be renewed about every 4 months whether used or not. Lamps, light carriers, and cords, after cleansing, are wiped with 95 per cent alcohol, and the light-carriers with the lamps in place are kept in a continuous sterilization box containing formaldehyde pastilles. It is of the utmost importance that instruments be always put away in perfect order. Not only are cleaning and oiling imperative, but any needed repairs should be attended to at once. Otherwise it will be inevitable that when gotten out in an emergency they will fail. In general surgery, a spoon will serve for a retractor and good work can be done with makeshifts; but in endoscopy, especially in the small, delicate, natural passages of children, the handicap of a defective or insufficient armamentarium may make all the difference between a success and a fatal failure. A bronchoscopic clinic should at all times be in the same state of preparedness for emergency as is everywhere required of a fire-engine house.
[PLATE I—A WORKING SET OF THE AUTHOR'S ENDOSCOPIC TUBES FOR LARYNGOSCOPY, BRONCHOSCOPY, ESOPHAGOSCOPY, AND GASTROSCOPY: A, Adult's laryngoscope; B, child's laryngoscope; C, anterior commissure laryngoscope; D, esophageal speculum, child's size; E, esophageal speculum, adult's size; F, bronchoscope, infant's size, 4 mm. X 30 cm.; G, bronchoscope, child's size, 5 mm. X 30 cm.; H, aspirating bronchoscope for adults, 7 mm. X 40 cm.; I, bronchoscope, adolescent's size, 7 mm. x 40 cm., used also for the deeper bronchi of adults; J, bronchoscope, adult size, g mm. x 40 cm.; K, child's size esophagoscope, 7 mm. X 45 cm.; L, adult's size esophagoscope, full lumen construction, 9 mm. x 45 cm.; M, adult's size gastroscope. C, I, and E are also hypopharyngoscopes. C is an excellent esophageal speculum for children, and a longer model is made for adults. If the utmost economy must be practised D, E, and M may be omitted. The balance of the instruments are indispensable if adults and children are to be dealt with. The instruments are made by Charles J. Pilling & Sons, Philadelphia.]
 CHAPTER II—ANATOMY OF LARYNX, TRACHEA, BRONCHI AND ESOPHAGUS, ENDOSCOPICALLY CONSIDERED
The larynx is a cartilaginous box, triangular in cross-section, with the apex of the triangle directed anteriorly. It is readily felt in the neck and is a landmark for the operation of tracheotomy. We are concerned endoscopically with four of its cartilaginous structures: the epiglottis, the two arytenoid cartilages, and the cricoid cartilage. The epiglottis, the first landmark in direct laryngoscopy, is a leaf-like projection springing from the anterointernal surface of the larynx and having for its function the directing of the bolus of food into the pyriform sinuses. It does not close the larynx in the trap-door manner formerly taught; a fact easily demonstrated by the simple insertion of the direct laryngoscope and further demonstrated by the absence of dysphagia when the epiglottis is surgically removed, or is destroyed by ulceration. Closure of the larynx is accomplished by the approximation of the ventricular bands, arytenoids and aryepiglottic folds, the latter having a sphincter-like action, and by the raising and tilting of the larynx. The arytenoids form the upper posterior boundary of the larynx and our particular interest in them is directed toward their motility, for the rotation of the arytenoids at the cricoarytenoid articulations determines the movements of the cords and the production of voice. Approximation of the arytenoids is a part of the mechanism of closure of the larynx.
The cricoid cartilage was regarded by esophagoscopists as the chief obstruction encountered on the introduction of the esophagoscope. As shown by the author, it is the cricopharyngeal fold, and the inconceivably powerful pull of the cricopharyngeal muscle on the cricoid cartilage, that causes the difficulty. The cricoid is pulled so powerfully back against the cervical spine, that it is hard to believe that this muscles is inserted into the median raphe and not into the spine itself (Fig. 68).
The ventricular bands or false vocal cords vicariously phonate in the absence of the true cords, and assist in the protective function of the larynx. They form the floor of the ventricles of the larynx, which are recesses on either side, between the false and true cords, and contain numerous mucous glands the secretion from which lubricates the cords. The ventricles are not visible by mirror laryngoscopy, but are readily exposed in their depths by lifting the respective ventricular bands with the tip of the laryngoscope. The vocal cords, which appear white, flat, and ribbon-like in the mirror, when viewed directly assume a reddish color, and reveal their true shelf-like formation. In the subglottic area the tissues are vascular, and, in children especially, they are prone to swell when traumatized, a fact which should be always in mind to emphasize the importance of gentleness in bronchoscopy, and furthermore, the necessity of avoiding this region in tracheotomy because of the danger of producing chronic laryngeal stenosis by the reaction of these tissues to the presence of the tracheotomic cannula.
The trachea just below its entrance into the thorax deviates slightly to the right, to allow room for the aorta. At the level of the second costal cartilage, the third in children, it bifurcates into the right and left main bronchi. Posteriorly the bifurcation corresponds to about the fourth or fifth thoracic vertebra, the trachea being elastic, and displaced by various movements. The endoscopic appearance of the trachea is that of a tube flattened on its posterior wall. In two locations it normally often assumes a more or less oval outline; in the cervical region, due to pressure of the thyroid gland; and in the intrathoracic portion just above the bifurcation where it is crossed by the aorta. This latter flattening is rhythmically increased with each pulsation. Under pathological conditions, the tracheal outline may be variously altered, even to obliteration of the lumen. The mucosa of the trachea and bronchi is moist and glistening, whitish in circular ridges corresponding to the cartilaginous rings, and reddish in the intervening grooves.
The right bronchus is shorter, wider, and more nearly vertical than its fellow of the opposite side, and is practically the continuation of the trachea, while the left bronchus might be considered as a branch. The deviation of the right main bronchus is about 25 degrees, and its length unbranched in the adult is about 2.5 cm. The deviation of the left main bronchus is about 75 degrees and its adult length is about 5 cm. The right bronchus considered as a stem, may be said to give off three branches, the epiarterial, upper- or superior-lobe bronchus; the middle-lobe bronchus; and the continuation downward, called the lower- or inferior-lobe bronchus, which gives off dorsal, ventral and lateral branches. The left main bronchus gives off first the upper-or superior-lobe bronchus, the continuation being the lower-or inferior-lobe bronchus, consisting of a stem with dorsal, ventral and lateral branches.
[FIG. 44.—Tracheo-bronchial tree. LM, Left main bronchus; SL, superior lobe bronchus; ML, middle lobe bronchus; IL, inferior lobe bronchus.]
The septum between the right and left main bronchi, termed the carina, is situated to the left of the midtracheal line. It is recognized endoscopically as a short, shining ridge running sagitally, or, as the patient lies in the recumbent position, we speak of it as being vertical. On either side are seen the openings of the right and left main bronchi. In Fig. 44, it will be seen that the lower border of the carina is on a level with the upper portion of the orifice of the right superior-lobe bronchus; with the carina as a landmark and by displacing with the bronchoscope the lateral wall of the right main bronchus, a second, smaller, vertical spur appears, and a view of the orifice of the right upper-lobe bronchus is obtained, though a lumen image cannot be presented. On passing down the right stem bronchus (patient recumbent) a horizontal partition or spur is found with the lumen of the middle-lobe bronchus extending toward the ventral surface of the body. All below this opening of the right middle-lobe bronchus constitutes the lower-lobe bronchus and its branches.
[FIG. 45.—Bronchoscopic views. S; Superior lobe bronchus; SL, superior lobe bronchus; I, inferior lobe bronchus; M, middle lobe bronchus.]
 Coming back to the carina and passing down the left bronchus, the relatively great distance from the carina to the upper-lobe bronchus is noted. The spur dividing the orifices of the left upper- and lower-lobe bronchi is oblique in direction, and it is possible to see more of the lumen of the left upper-lobe bronchus than of its homologue on the right. Below this are seen the lower-lobe bronchus and its divisions (Fig. 45).
Dimensions of the Trachea and Bronchi.—It will be noted that the bronchi divide monopodially, not dichotomously. While the lumina of the individual bronchi diminish as the bronchi divide, the sum of the areas shows a progressive increase in total tubular area of cross-section. Thus, the sum of the areas of cross-section of the two main bronchi, right and left, is greater than the area of cross section of the trachea. This follows the well known dynamic law. The relative increase in surface as the tubes branch and diminish in size increases the friction of the passing air, so that an actual increase in area of cross section is necessary, to avoid increasing resistance to the passage of air.
The cadaveric dimensions of the tracheobronchial tree may be epitomized approximately as follows: Adult Male Female Child Infant Diameter trachea, 14 X 20 12 X 16 8 X 10 6 X 7 Length trachea, cm. 12.0 10.0 6.0 4.0 Length right bronchus 2.5 2.5 2.0 1.5 Length left bronchus 5.0 5.0 3.0 2.5 Length upper teeth to trachea 15.0 23.0 10.0 9.0 Length total to secondary bronchus 32.0 28.0 19.0 15.0
In considering the foregoing table it is to be remembered that in life muscle tonus varies the lumen and on the whole renders it smaller. In the selection of tubes it must be remembered that the full diameter of the trachea is not available on account of the glottic aperture which in the adult is a triangle measuring approximately 12 X 22 X 22 mm. and permitting the passage of a tube not over 10 mm. in diameter without risk of injury. Furthermore a tube which filled the trachea would be too large to enter either main bronchus.
The normal movements of the trachea and bronchi are respiratory, pulsatory, bechic, and deglutitory. The two former are rhythmic while the two latter are intermittently noted during bronchoscopy. It is readily observed that the bronchi elongate and expand during inspiration while during expiration they shorten and contract. The bronchoscopist must learn to work in spite of the fact that the bronchi dilate, contract, elongate, shorten, kink, and are dinged and pushed this way and that. It is this resiliency and movability that make bronchoscopy possible. The inspiratory enlargement of lumen opens up the forceps spaces, and the facile bronchoscopist avails himself of the opportunity to seize the foreign body.
A few of the anatomical details must be kept especially in mind when it is desired to introduce straight and rigid instruments down the lumen of the gullet. First and most important is the fact that the esophageal walls are exceedingly thin and delicate and require the most careful manipulation. Because of this delicacy of the walls and because the esophagus, being a constant passageway for bacteria from the mouth to the stomach, is never sterile, surgical procedures are associated with infective risks. For some other and not fully understood reason, the esophagus is, surgically speaking, one of the most intolerant of all human viscera. The anterior wall of the esophagus is in a part of its course, in close relation to the posterior wall of the trachea, and this portion is called the party wall. It is this party wall that contains the lymph drainage system of the posterior portion of the larynx, and it is largely by this route that posteriorly located malignant laryngeal neoplasms early metastasize to the mediastinum.
 [FIG 46.—Esophagoscopic and Gastroscopic Chart
BIRTH 1 yr. 3 yrs. 6 yrs. 10 yrs. 14 yrs.ADULTS 23 27 30 33 36 43 53 Cm. GREATER CURVATURE 18 20 22 25 27 34 40 Cm. CARDIA 19 21 23 24 25 31 36 Cm. HIATUS 13 15 16 18 20 24 27 Cm. LEFT BRONCHUS 12 14 15 16 17 21 23 Cm. AORTA 7 9 10 11 12 14 16 Cm. CRICOPHARYINGEUS 0 0 0 0 0 0 0 Cm. INCISORS FIG. 46.—The author's esophagoscopic chart of approximate distances of the esophageal narrowings from the upper incisor teeth, arranged for convenient reference during esophagoscopy in the dorsally recumbent patient.]
The lengths of the esophagus at different ages are shown diagrammatically in Fig. 46. The diameter of the esophageal lumen varies greatly with the elasticity of the esophageal walls; its diameter at the four points of anatomical constriction is shown in the following table:
Constriction Diameter Vertebra
Cricopharyngeal Transverse 23 mm. (1 in.) Sixth cervical Antero-posterior 17 mm. (3/4 in.) Aortic Transverse 24 mm. (1 in.) Fourth thoracic Antero-posterior 19 mm. (3/4 in.) Left-bronchial Transverse 23 mm. (1 in.) Fifth thoracic Antero-posterior 17 mm. (3/4 in.) Diaphragmatic Transverse 23 mm. (1 in+) Tenth thoracic Antero-posterior 23 mm. (in.—)
For practical endoscopic purposes it is only necessary to remember that in a normal esophagus, straight and rigid tubes of 7 mm. diameter should pass freely in infants, and in adults, tubes of 10 mm.
The 4 demonstrable constrictions from above downward are at 1. The crico-pharyngeal fold. 2. The crossing of the aorta. 3. The crossing of the left bronchus. 4. The hiatus esophageus. There is a definite fifth narrowing of the esophageal lumen not easily demonstrated esophagoscopically and not seen during dissection, but readily shown functionally by the fact that almost all foreign bodies lodge at this point. This narrowing occurs at the superior aperture of the thorax and is probably produced by the crowding of the numerous organs which enter or leave the thorax through this orifice.
The crico-pharyngeal constriction, as already mentioned, is produced by the tonic contraction of a specialized band of the orbicular fibers of the lowermost portion of the inferior pharyngeal constrictor muscle, called the cricopharyngeal muscle. As shown by the author it is this muscle and not the cricoid cartilage alone that causes the difficulty in the insertion of an esophagoscope.
This muscle is attached laterally to the edges of the signet of the cricoid which it pulls with an incomprehensible power against the posterior wall of the hypopharynx, thus closing the mouth of the esophagus. Its other attachment is in the median posterior raphe. Between these circular fibers (the cricopharyngeal muscle) and the oblique fibers of the inferior constrictor muscle there is a weakly supported point through which the esophageal wall may herniate to form the so-called pulsion diverticulum. It is at this weak point that fatal esophagoscopic perforation by inexperienced operators is most likely to occur.
The aortic narrowing of the esophagus may not be noticed at all if the patient is placed in the proper sequential "high-low" position. It is only when the tube-mouth is directed against the left anterior wall that the actively pulsating aorta is felt.
The bronchial narrowing of the esophagus is due to backward displacement caused by the passage of the left bronchus over the anterior wall of the esophagus at about 27 cm. from the upper teeth in the adult. The ridge is quite prominent in some patients, especially those with dilatation from stenoses lower down.
The hiatal narrowing is both anatomic and spasmodic. The peculiar arrangement of the tendinous and muscular structure of the diaphragm acts on this hiatal opening in a sphincter-like fashion. There are also special bundles of muscle fibers extending from the crura of the diaphragm and surrounding the esophagus, which contribute to tonic closure in the same way that a pinch-cock closes a rubber tube. The author has called the hiatal closure the "diaphragmatic pinchcock."
Direction of the Esophagus.—The esophagus enters the chest in a decidedly backward as well as downward direction, parallel to that of the trachea, following the curves of the cervical and upper dorsal spine. Below the left bronchus the esophagus turns forward, passing through the hiatus in the diaphragm anterior to and to the left of the aorta. The lower third of the esophagus in addition to its anterior curvature turns strongly to the left, so that an esophagoscope inserted from the right angle of the mouth, when introduced into the stomach, points in the direction of the anterior superior spine of the left ileum.
It is necessary to keep this general course constantly in mind in all cases of esophagoscopy, but particularly in those cases in which there is marked dilatation of the esophagus following spasm at the diaphragm level. In such cases the aid of this knowledge of direction will greatly simplify the finding of the hiatus esophageus in the floor of the dilatation.
The extrinsic or transmitted movements of the esophagus are respiratory and pulsatory, and to a slight extent, bechic. The respiratory movements consist in a dilatation or opening up of the thoracic esophageal lumen during inspiration, due to the negative intrathoracic pressure. The normal pulsatory movements are due to the pulsatile pressure of the aorta, found at the 4th thoracic vertebra (24 cm. from the upper teeth in the adult), and of the heart itself, most markedly felt at the level of the 7th and 8th thoracic vertebrae (about 30 cm. from the upper teeth in adults). As the distances of all the narrowings vary with age, it is useful to frame and hang up for reference a copy of the chart (Fig. 46).
The intrinsic movements of the esophagus are involuntary muscular contractions, as in deglutition and regurgitation; spasmodic, the latter usually having some pathologic cause; and tonic, as the normal hiatal closure, in the author's opinion may be considered. Swallowing may be involuntary or voluntary. The constrictors are anatomically not considered part of esophagus proper. When the constrictors voluntarily deliver the bolus past the cricopharyngeal fold, the involuntary or peristaltic contractions of the esophageal mural musculature carry the bolus on downward. There is no sphincter at the cardiac end of the esophagus. The site of spasmodic stenosis in the lower third, the so-called cardiospasm, was first demonstrated by the author to be located at the hiatus esophageus and the spasmodic contractions are of the specialized muscle fibers there encircling the esophagus, and might be termed "phrenospasm," or "hiatal esophagismus." Regurgitation of food from the stomach is normally prevented by the hiatal muscular diaphragmatic closure (called by the author the "diaphragmatic pinchcock") plus the kinking of the abdominal esophagus.
In the author's opinion there is no spasm in the disease called "cardiospasm." It is simply the failure of the diaphragmatic pinchcock to open normally in the deglutitory cycle. A better name is functional hiatal stenosis.
At retrograde esophagoscopy the cardia and abdominal esophagus do not seem to exist. The top of the stomach seems to be closed by the diaphragmatic pinchcock in the same way that the top of a bag is closed by a puckering string.
 CHAPTER III—PREPARATION OF THE PATIENT FOR PERORAL ENDOSCOPY
The suggestions of the author in the earlier volumes in regard to preparation of the patient, as for any operation, by a bath, laxative, etc., and especially by special cleansing of the mouth with 25 per cent alcohol, have received general endorsement. Care should be taken not to set up undue reaction by vigorous scrubbing of gums unaccustomed to it. Artificial dentures should be removed. Even if no anesthetic is to be used, the patient should be fasted for five hours if possible, even for direct laryngoscopy in order to forestall vomiting. Except in emergency cases every patient should be gone over by an internist for organic disease in any form. If an endolaryngeal operation is needed by a nephritic, preparatory treatment may prevent laryngeal edema or other complications. Hemophilia should be thought of. It is quite common for the first symptom of an aortic aneurysm to be an impaired power to swallow, or the lodgment of a bolus of meat or other foreign body. If aneurysm is present and esophagoscopy is necessary, as it always is in foreign body cases, "to be fore-warned is to be forearmed." Pulmonary tuberculosis is often unsuspected in very young children. There is great danger from tracheal pressure by an esophageal diverticulum or dilatation distended with food; or the food maybe regurgitated and aspirated into the larynx and trachea. Therefore, in all esophageal cases the esophagus should be emptied by regurgitation induced by titillating the fauces with the finger after swallowing a tumblerful of water, pressure on the neck, etc. Aspiration will succeed in some cases. In others it is absolutely necessary to remove food with the esophagoscope. If the aspirating tube becomes clogged by solid food, the method of swab aspiration mentioned under bronchoscopy will succeed. Of course there is usually no cough to aid, but the involuntary abdominal and thoracic compression helps. Should a patient arrive in a serious state of water-hunger, as part of the preparation the patient must be given water by hypodermoclysis and enteroclysis, and if necessary the endoscopy, except in dyspneic cases, must be delayed until the danger of water-starvation is past.
As pointed out by Ellen J. Patterson the size of the thymus gland should be studied before an esophagoscopy is done on a child.
Every patient should be examined by indirect, mirror laryngoscopy as a preliminary to peroral endoscopy for any purpose whatsoever. This becomes doubly necessary in cases that are to be anesthetized.
 CHAPTER IV—ANESTHESIA FOR PERORAL ENDOSCOPY
A dyspneic patient should never be given a general anesthetic. Cocaine should not be used on children under ten years of age because of its extreme toxicity. To these two postulates always in mind, a third one, applicable to both general and local anesthesia, is to be added—total abolition of the cough-reflex should be for short periods only. General anesthesia is never used in the Bronchoscopic Clinic for endoscopic procedures. The choice for each operator must, however, be a matter for individual decision, and will depend upon the personal equation, and degree of skill of the operator, and his ability to quiet the apprehensions of the patient. In other words, the operator must decide what is best for his particular patient under the conditions then existing.
Children in the Bronchoscopic Clinic receive neither local nor general anesthesia, nor sedative, for laryngoscopic operations or esophagoscopy. Bronchoscopy in the older children when no dyspnea is present has in recent years, at the suggestion of Prof. Hare, been preceded by a full dose of morphin sulphate (i.e., 1/8 grain for a child of six years) or a full physiologic dose of sodium bromide. The apprehension is thus somewhat allayed and the excessive cough-reflex quieted. The morphine should be given not less than an hour and a half before bronchoscopy to allow time for the onset of the soporific and antispasmodic effects which are the desiderata, not the analgesic effects. Dosage is more dependent on temperament than on age or body weight. Atropine is advantageously added to morphine in bronchoscopy for foreign bodies, not only for the usual reasons but for its effect as an antispasmodic, and especially for its diminution of endobronchial secretions. True, it does not diminish pus, but by diminishing the outpouring of normal secretions that dilute the pus the total quantity of fluid encountered is less than it otherwise would be. In cases of large quantities of pus, as in pulmonary abscess and bronchiectasis, however, no diminution is noticeable. No food or water is allowed for 5 hours prior to any endoscopic procedure, whether sedatives or anesthetics are to be given or not. If the stomach is not empty vomiting from contact of the tube in the pharynx will interfere with work.
With adults no anesthesia, general or local, is given for esophagoscopy. For laryngeal operation and bronchoscopy the following technic is used:
One hour before operation the patient is given hypodermatically a full physiologic dose of morphin sulphate (from 1/4, to 3/8 gr.) guarded with atropin sulphate (gr. 1/150). Care must be taken that the injection be not given into a vein. On the operating table the epiglottis and pharynx are painted with 10 per cent solution of cocain. Two applications are usually sufficient completely to anesthetize the exterior and interior of the larynx by blocking of the superior laryngeal nerve without any endolaryngeal applications. The laryngoscope is now introduced and if found necessary a 20 per cent cocain solution is applied to the interior of the larynx and subglottic region, by means of gauze swabs fastened to the sponge carriers. Here also two applications are quite sufficient to produce complete anesthesia in the larynx. If bronchoscopy is to be done the gauze swab is carried down through the exposed glottis to the carina, thus anesthetizing the tracheal mucosa. If further anesthetization of the bronchial mucosa is required, cocain may be applied in the same manner through the bronchoscope. In all these local applications prolonged contact of the swab is much more efficient than simply painting the surface.
 In cases in which cocain is deemed contraindicated morphin alone is used. If given in sufficient dosage cocain can be altogether dispensed with in any case.
It is perhaps safer for the beginner in his early cases of esophagoscopy to have the patient relaxed by an ether anesthesia, provided the patient is not dyspneic to begin with, or made so by faulty position or by pressure of the esophagoscopic tube mouth on the tracheoesophageal "party wall." As proficiency develops, however, he will find anesthesia unnecessary. Local anesthesia is needless for esophagoscopy, and if used at all should be limited to the laryngopharynx and never applied to the esophagus, for the esophagus is without sensation, as anyone may observe in drinking hot liquids.
Direct laryngoscopy in children requires neither local nor general anesthesia, either for diagnosis or for removal of foreign bodies or growths from the larynx. General anesthesia is contraindicated because of the dyspnea apt to be present, and because the struggles of the patient might cause a dislodgment of the laryngeal intruder and aspiration to a lower level. The latter accident is also prone to follow attempts to cocainize the larynx.
Technic for General Anesthesia.—For esophagoscopy and gastroscopy, if general anesthesia is desired, ether may be started by the usual method and continued by dropping upon folded gauze laid over the mouth after the tube is introduced. Endo-tracheal administration of ether is, however, far safer than peroral administration, for it overcomes the danger of respiratory arrest from pressure of the esophagoscope, foreign body, or both, on the trachea. Chloroform should not be used for esophagoscopy or gastroscopy because of its depressant action on the respiratory center.
For bronchoscopy, ether or chloroform may be started in the usual way and continued by insufflating through the branch tube of the bronchoscope by means of the apparatus shown in Fig. 13.
In case of paralysis of the larynx, even if only monolateral, a general anesthetic if needed should be given by intratracheal insufflation. If the apparatus for this is not available the patient should be tracheotomized. Hence, every adult patient should be examined with a throat mirror before general anesthesia for any purpose, and the necessity becomes doubly imperative before goiter operations. A number of fatalities have occurred from neglect of this precaution.
Anesthetizing a tracheotomized patient is free from danger so long as the cannula is kept free from secretion. Ether is dropped on gauze laid over the tracheotomic cannula and the anesthesia watched in the usual manner. If the laryngeal stenosis is not complete, ether-saturated gauze is to be placed over the mouth as well as over the tracheotomy tube.
Endo-tracheal anesthesia is by far the safest way for the administration of ether for any purpose. By means of the silk-woven catheter introduced into the trachea, ether-laden air from an insufflation apparatus is piped down to the lungs continuously, and the strong return-flow prevents blood and secretions from entering the lower air-passages. The catheter should be of a size, relative to that of the glottic chink, to permit a free return-flow. A number 24 French is readily accommodated by the adult larynx and lies well out of the way along the posterior wall of the larynx. Because of the little room occupied by the insufflation catheter this method affords ideal anesthesia for external laryngeal operations. Operations on the nose, accessory sinuses and the pharynx, apt to be attended by considerable bleeding, are rendered free from the danger of aspiration pneumonia by endotracheal anesthesia. It is the safest anesthesia for goiter operations. Endo-tracheal anesthesia has rendered needless the intricate negative pressure chamber formerly required for thoracic surgery, for by proper regulation of the pressure under which the ether ladened air is delivered, a lung may be held in any desired degree of expansion when the pleural cavity is opened. It is indicated in operations of the head, neck, or thorax, in which there is danger of respiratory arrest by centric inhibition or peripheral pressure; in operations in which there is a possibility of excessive bleeding and aspiration of blood or secretions; and in operations where it is desired to keep the anesthetist away from the operating field. Various forms of apparatus for the delivery of the ether-laden vapor are supplied by instrument makers with explicit directions as to their mechanical management.